THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 
MRS.  PRUDENCE  W.  KOFOID 


THE 


MORBID  ANATOMY 


OF 


SOME  OF  THE  MOST  IMPORTANT  PARTS 


OF  THE 


HUMAN  BODY 


BY 
MATTHEW  BAILLIE,  M.  D.  F.  R.  S. 

I'HYSICIAN  EXTRAORDINABY  TO  THE  KING,    FELLOW  OF  THE  ROYAL  COLLEGE  OF 

1'IIYSICIANS  IX  LONDON,    AND  HONORARY  FELLOW  OF  THE  BOYAL  COLLEGE 

OF  PHYSICIANS  IN  EDINBURGH,   &C.  &C.  &C. 


THIRD  AMERICAN  FROM  THE  FIFTH  LONDON  EDITION 


PHILADELPHIA : 

PRINTED  AND  PUBLISHED  BY  HICKMAN  AND  HAZZARJ', 

No.  15,  North  Front  Street- 
1820. 


I 


TO 


DAVID  PITCAIRN,  M.  D. 

F.  R.  S.  &c.  &c.  fcc. 

AS  A 

TESTIMONY  OF  HIGH  ESTEEM  FOR 

HIS  CHARACTER, 
AND  OF  GRATITUDE  FOR  MANY  KIND 

OFFICES, 

THIS  WORK 

IS   INSCRIBED, 
BY  HIS  FAITHFUL  FRIEND  AND  SERVANT 

MATTHEW  BAILLIE. 


*?£-  '••.'"- 


PREFACE 


TO  THE  FIRST  EDITION. 

SOME  diseases  consist  only  in  morbid  actions,  but  do 
not  produce  any  change  in  the  structure  of  parts :  these 
do  not  admit  of  anatomical  enquiry  after  death.  There 
are  other  diseases,  however,  where  alterations  in  the  struc- 
ture take  place,  and  these,  become,  the  proper  subjects  of 
anatomical  examination. 

The  object  of  this  work  is  to  explain,  more  minutely 
than  has  hitherto  been  done,  the  changes  of  structure 
arising  from  morbid  actions  in  some  of  the  most  important 
parts  of  the  human  body. 

This,  1  hope,  will  be  attended  with  some  advantage  to 
the  general  science  of  medicine,  and  ultimately  to  its  prac- 
tice. It  is  very  much  to  be  regretted  that  the  knowledge 
of  morbid  structure  does  not  lead  with  certainty  to  the 
knowledge  of  morbid  actions,  although  the  one  be  the  effect 
of  the  other ;  yet  surely  it  lays  the  most  solid  foundation  for 
prosecuting  such  enquiries  with  success.  In  proportion, 
therefore,  as  we  shall  become  acquainted  with  the  changes 
produced  in  the  structure  of  parts  from  diseased  actions, 
we  shall  be  more  likely  to  make  some  progress  towards 
a  knowledge  of  the  actions  themselves,  although  it  must 
be  very  slowly.  The  subject  in  itself  is  extremely  difficult, 
because  morbid  actions  are  going  on  in  the  minute  parts 
of  an  animal  body  excluded  from  observation;  but  still 
the  examination  of  morbid  structure  is  one  of  the  most 
probable  means  of  throwing  light  upon  it. 

A  second  advantage  arising  from  the  more  attentive 


vi  PREFACE  TO  THE 

examination  of  morbid  structure  is,  that  we  shall  be  able 
to  distinguish  between  changes  which  may  have  some 
considerable  resemblance  to  each  other,  and  which  have 
been  generally  confounded.  This  will  ultimately  lead  to 
a  more  attentive  observation  of  symptoms  while  morbid 
actions  are  taking  place,  and  be  the  means  of  distinguishing 
diseases  with  greater  accuracy.  When  this  has  been  done, 
it  may,  perhaps,  produce  a  successful  enquiry  after  the 
most  proper  method  of  treatment. 

Another  advantage  arising  from  a  more  attentive  obser- 
vation of  morbid  structure  is,  that  we  shall  be  better  fitted 
to  detect  diseased  alterations  in  the  organization  of  parts 
which  are  but  little,  or  not  at  all  known.  This  will  lay 
the  foundation  of  our  enquiry  into  the  diseases  themselves, 
so  that  we  shall  add  to  our  knowledge  of  the  pathology  of 
the  body,  and  perhaps  also  to  our  knowledge  of  remedies, 

A  fourth  advantage  still  from  observing  attentively 
morbid  structure  is,  that  theories  taken  up  hastily  about 
diseases  will  be  occasionally  corrected.  The  human  mind 
is  prone  to  form  opinions,  upon  every  subject  which  is 
presented  to  it,  but  from  a  natural  indolence  is  frequently 
averse  to  inquire  into  the  circumstances  which  can  alone 
form  a  sufficient  ground  for  them.  This  is  the  most  gen- 
eral  cause  of  false  opinions,  which  have  not  only  pervaded 
medicine,  but  almost  every  other  branch  of  knowledge. 
When,  however,  the  mind  shall  be  oblidged  to  observe 
facts  which  cannot  be  reconciled  with  such  opinions,  it 
will  be  evident  that  the  opinions  are  ill  founded,  and  they 
will  be  laid  aside.  We  grant,  it  does  not  always  happen 
that  men  are  induced  to  give  up  their  opinions,  or  even  to 
think  them  wrong,  upon  observing  facts  which  do  not 
agree  with  them,  but  surely  it  is  the  best  means  of  pro- 


FIRST  EDITION.  vii 

ducing  this  effect;  and  whatever  change  may  be  wrought 
on  the  individuals  themselves,  the  world  will  be  convinced 
which  has  fewer  prejudices  to  combat. 

A  person  who  previously  had  attended  very  accurately 
to  symptoms,  but  was  unacquainted  with  the  disease, 
when  he  comes  to  examine  the  body  after  death,  and  finds 
some  of  the  appearances  that  are  described  in  this  Treatise, 
will  acquire  a  knowledge  of  the  whole  disease.  He  will  be 
able  to  guide  himself  on  such  knowledge  in  similar  cases, 
and  also  to  inform  others.  It  may  perhaps,  too,  lead  him 
to  a  proper  method  of  treatment. 

When  a  person  has  become  well  acquainted  with  dis- 
eased appearances,  he  will  be  better  able  to  make  his 
remarks,  in  examining  dead  bodies,  so  as  to  judge  more 
accurately  how  far  the  symptoms  and  the  appearances 
agree  with  each  other ;  he  will  be  able  also  to  give  a  more 
distinct  account  of  what  he  has  observed,  so  that  his  data 
will  become  a  more  accurate  ground  of  reasoning  for  others. 

The  natural  structure  of  the  different  parts  of  the  human 
body  has  been  very  minutely  examined,  so  that  anatomy 
may  be  said  to  have  arrived  at  a  high  pitch  of  perfection ; 
but  our  knowledge  of  the  changes  of  structure  produced 
by  disease,  which  may  be  called  the  Morbid  Anatomy, 
is  still  very  imperfect.  Such  changes  have  commonly 
been  observed  only  in  their  more  obvious  appearances, 
and  very  seldom  with  much  minuteness  or  accuracy  of 
discrimination. 

Any  works  explaining  morbid  structure  which  I  have 
seen,  are  very  different  in  their  plan  from  the  present :  they 
either  consist  of  cases  containing  an  account  of  diseases 
and  dissections  collected  together  in  periodical  publications, 
without  any  natural  connection  among  each  other :  or  con- 


Yiii  PREFACE  TO  THE 

sist  of  very  large  collections  of  cases,  arranged  according 
to  some  order.  In  some  of  these  periodical  works,  the 
diseased  structure  has  been  frequently  explained  with  a 
sufficient  degree  of  accuracy,  but  in  all  the  larger  works 
it  has  been  often  described  too  generally.  The  descrip- 
tions too  of  the  principal  diseased  appearances,  have  been 
sometimes  obscured,  by  taking  notice  of  smaller  collateral 
circumstances,  which  had  no  connection  with  them,  or 
the  diseases  from  whence  they  arose.  Both  of  these  faults 
too  frequently  occur,  even  in  the  stupendous  work  of 
Morgagni  de  Causis  et  Sedibus  Morborum,  upon  which, 
when  considered  in  all  its  parts,  it  would  be  difficult  to 
bestow  too  high  praise.  Besides,  the  bulk  of  these  very 
large  collections  prevents  them  from  being  generally  in  the 
possession  of  practitioners,  and  also  renders  them  more 
difficult  to  consult. 

In  the  present  work  it  is  proposed  not  to  give  cases ; 
but  simply  an  account  of  the  morbid  changes  of  structure 
which  take  place  in  the  thoracic  and  abdominal  viscera,  in 
the  organs  of  generation  in  both  sexes,  and  in  the  brain. 
This  will  be  done  according  to  a  local  arrangement,  very 
much  in  the  same  manner  as  if  we  were  describing  natural 
structure,  and  will  be  accompanied  with  observations  upon 
morbid  actions  which  may  occasionally  arise.  My  situa- 
tion has  given  me  more  than  the  ordinary  opportunities  of 
examining  morbid  structure.  Dr.  Hunter's  collection 
contains  a  very  large  number  of  preparations  exhibiting 
morbid  appearances,  which  I  can  have  recourse  to  at  any 
time  for  examination.  Being  physician  to  a  large  hospital, 
and  engaged  in  teaching  anatomy,  I  have  also  very  frequent 
opportunities  of  examining  diseases  in  dead  bodies.  This 
work  will  therefore  chiefly  contain  an  account  of  the  mor- 


FIRST  FDITION.  ix 

bid  appearances  which  I  have  seen  myself;  but  I  shall  also 
take  advantage  of  what  has  been  observed  by  others.  It 
is  intended  to  comprehend  an  account  of  the  most  common, 
as  well  as  many  of  the  very  rare  appearances  of  disease  in 
the  vital  and  more  important  parts  of  the  human  body* 
From  the  nature  of  this  undertaking  it  is  evident,  that  it 
must  be  progressive :  some  appearances  of  disease  will  be 
observed  in  future,  with  which  we  are  at  present  totally 
unacquainted,  and  others  which  we  know  very  little  of 
now,  will  afterwards  be  known  perfectly. 

Although  I  have  ventured  to  lay  this  work  before  the 
Public,  yet  I  am  very  sensible  of  its  imperfections.  Some 
appearances  are  described  which  I  have  only  had  an  op- 
portunity of  seeing  once,  and  which,  therefore,  may  be 
supposed  to  be  described  less  fully  and  exactly  than  if  I  had 
been  able  to  make  repeated  examinations.  There  are  others 
which  I  have  seen  long  before  I  had  formed  any  idea  of 
this  undertaking,  and  which  I  may  be  supposed  to  have 
observed  less  accurately  than  if  I  had  had  a  particular  ob- 
ject in  view.  There  are  others  still,  which  I  have  only 
had  an  opportunity  of  examining  in  preparations.  In  some 
of  these,  certain  appearances  may  be  supposed  to  be  lost, 
which  might  have  been  observed  had  they  been  examined 
recently  after  death.  All  of  these  are  sources  of  inaccu- 
racy, which  may  be  said  in  some  degree  to  be  unavoidable. 
I  have  endeavoured,  however,  to  be  accurate ;  and  if  the 
Public  should  approve  of  my  plan,  I  shall  be  very  careful, 
by  the  addition  of  new  materials,  and  by  repeated  obser- 
vations, to  render  this  publication  less  imperfect. 


PREFACE 


TO  THE  SECOND  EDITION. 

A  SECOND  Edition  of  this  Treatise  is  now  offered  to 
the  Public.  It  is  considerably  enlarged,  and  I  hope  more 
correct  than  the  former.  The  additions  are  principally 
derived  from  what  I  have  remarked  myself ;  but  they  are 
also  taken  from  the  observations  of  others,  and  more 
especially  from  those  of  Dr.  Soemmerring,  Professor  of 
Medicine  in  the  University  of  Mayence,  one  of  the  most 
distinguished  anatomists  in  Germany.  He  was  pleased 
to  think  so  favourably  of  my  attempt  to  improve  the 
knowledge  of  diseased  appearances  in  the  human  body,  as 
to  translate  the  first  Edition  of  the  Morbid  Anatomy  into 
the  German  language,  and  to  add  to  it  many  new  Cases, 
and  copious  Notes.  It  has  given  me  the  most  sincere 
satisfaction,  to  find  that  our  observations  and  opinions 
coincide  so  much  with  those  of  each  other.  Had  the 
plan  of  my  work  been  different,  I  might  have  derived 
much  more  assistance  from  the  valuable  labours  of  Pro- 
fessor Soemmerring,  but  many  of  the  additions  which  he 
has  made  do  not  strictly  fall  within  it. 

To  the  Morbid  Appearances  I  have  attempted  to  sub- 
join the  Symptoms  connected  with  them.  This  part  of 
the  undertaking  is  attended  with  many  difficulties,  and  I 
feel  very  sensibly,  how  much  the  execution  of  it  stands  in 
need  of  the  kind  indulgence  of  the  Public.  If  this  work 


PREFACE  TO  THE  ki 

shall  ever  come  to  another  Edition,  I  hope  to  be  able  to 
render  the  account  of  Symptoms  less  imperfect. 

The  difficulties  which  attend  an  attempt  to  ascertain  the 
symptoms  of  diseases,  are  derived  from  various  sources. 
The  same  symptoms  are  not  uniformly  connected  with  the 
same  changes  of  morbid  structure  in  the  body. — In  many 
cases  too  the  symptoms  are  nearly  the  same,  where  the 
morbid  changes  of  structure  are  very  different.  This  is 
particularly  exemplified  in  diseases  of  the  brain,  and  of  the 
heart. — Patients  often  explain  very  imperfectly  their  feel- 
ings, partly  from  the  natural  deficiency  of  language,  and 
partly  from  being  misled  by  preconceived  opinions  about 
the  nature  of  their  complaints. — Medical  men  also,  in  ex- 
amining into  the  symptoms  of  diseases,  sometimes  put 
their  questions  inaccurately,  and  not  unfrequently  mislead 
patients  into  a  false  description,  from  some  opinion  about 
the  disease  which  they  have  too  hastily  adopted.  All  of 
these  are  formidable  difficulties,  which  obstruct  the  progress 
of  our  knowledge  of  the  symptoms  of  diseases;  but  the 
accumulated  observations  of  many  individuals  will  probably, 
at  length,  in  a  great  measure  overcome  them. 

In  describing  the  symptoms  of  diseases,  I  have  not 
entered  into  a  minute  detail.  This  belongs  properly  to  the 
plan  of  a  writer,  who  proposes  to  take  a  full  view  of  any 
particular  disease.  I  have  mentioned  those  symptoms  only 
which  are  most  constant,  and  most  strongly  characteristic 
of  the  diseases  to  which  they  belong.  Many  diseased  ap- 
pearances are  described  in  this  work,  to  which  there  are 
added  no  corresponding  symptoms;  and  this  depends  upon 
different  causes.  The  first  is,  that  there  are  many  morbid 
changes  of  structure  in  the  body,  the  corresponding  symp- 
toms of  which  are  not  ascertained.  The  second  is-,  that 


xii  SECOND  EDITION. 

many  morbid  changes  of  structure  are  produced  by  causes 
which  disturb  the  constitution  so  little,  as  to  be  attended 
with  symptoms  too  slightly  marked  for  observation.  The 
third  and  last  is,  that  rhe  symptoms  belonging  to  some 
diseased  appearances,  fall  so  immediately  under  the  cogni- 
zance of  the  eye,  or  of  the  touch,  as  to  be  included  in  a 
description  of  the  diseased  appearances  themselves,  and  to 
render  any  further  account  of  them  superfluous. 

The  account  of  symptoms  is  placed  at  the  end  of  each 
chapter,  after  the  description  of  the  diseased  appearances, 
that  the  anatomical  part  of  the  work  may  not  be  interrupted. 
In  a  very  few  instances,  however,  the  account  of  the  symp- 
toms has  not  been  separated  from  the  anatomical  description 
of  the  morbid  appearances,  viz.  where  so  little  of  the 
symptoms  was  known  as  not  to  admit  of  a  distinct  account 
being  given  to  them. 

Besides  an  account  of  morbid  appearances,  a  few  cases 
of  malformation  are  blended  in  this  work.  They  do  not 
strictly  fall  within  its  plan;  I  have,  therefore,  added  only  a 
few,  which  are  important,  and  which  have  almost  all 
occurred  to  my  own  observation. 


ADVERTISEMENT 

TO  THE  FIFTH  EDITION. 

In  the  year  1807  a  translation  of  my  Treatise  upon 
Morbid  Anatomy  into  the  Italian  language  was  made  by 
Dr.  Gentilini,  which  was  published  at  Pavia ;  but  a  copy 
of  it  was  not  sent  to  me  by  the  Translator  till  about  two 
years  ago.  A  new  translation  of  this  Treatise  into  the 
French  language  has  also  been  made  in  1815  by  Mr. 
Guerbois,  a  surgeon  of  reputation  at  Paris.  Both  transla- 
tions are  faithful,  and  are  accompanied  with  some  judicious 
notes,  which  I  have  read  with  attention  and  advantage. 
The  present  edition  of  my  book  is  somewhat  enlarged, 
and  is  corrected,  according  as  some  of  my  observations 
have  appeared  to  be  extended  or  limited  by  greater  ex- 
perience, 


CONTENTS, 


CHAPTER  I. 

Diseased  appearances  of  the  Pericardium.  i 

Inflammation  of  the  pericardium. — Adhesions  of  the  pericardium 
to  the  heart. — Dropsy  of  the  pericardium. — Scrofulous  tu- 
mours in  the  pericardium. — The  pericardium  almost  dry. — 
The  pericardium  cartilaginous  and  bony.— The  pericardium 
wanting. — Symptoms. 

CHAPTER.  II. 

Diseased  Appearances  of  the  Heart.  12 

Inflammation  of  the  heart.— White  spot  upon  the  surface  of  the 
heart. — Polypus. — Aneurysm  of  the  heart.— Aneurysm  of  the 
arch  of  the  aorta. — Ossification  of  the  coronory  arteries. — Ossi- 
fication of  the  semilunar  valves. — semilunar  valves  thick  and 
opaque.' — Rupture  of  the  valves. — Valves  between  the  auricles 
and  the  ventricles  ossified. — The  same  valves  thick  and  opaque. — 
Rupture  of  the  heart. — Blood  in  the  pericardium,  without  a 
rupture  of  the  heart. — Mai-formations  of  the  heart — Heart 
enlarged. — Hydatids  adhering  to  the  heart. — A  portion  of  the 
heart  bony  or  earthy. — Symptoms. 

CHAPTER  III. 

Diseased  Appearances  in  the  Cavity  of  the  Thorax.  32 

Inflammation.— Adhesions    in   the  cavity  of  the  thorax. — Em- 

pyema. — Hydrothroax. — Steatomatous  tumours  and  hydatids. — 

The  pleura  almost  dry. — Ossification  of  the  pleura. — Symptoms. 

CHAPTER  IV. 

Diseased  Appearances  of  the  Lungs.  41 

Inflammation. — Abscesses. — Tubercles. — Soft  pulpy  tubercle.— 
Water  accumulated  in  the  substance  of  the  lungs. — Lungs 
distended  with  air. — Air  cells  of  the  lungs  enlarged. — Air 
vesicles  attached  to  the  edge  of  the  lungs. — Lungs  changed 
into  a  substance  like  liver.— Lungs  converted  into  bone.— A 


CONTENTS.  xv 

solid  tumour  compressing  the  lungs. — Earthy  concretions  in 
the  lungs. — Hydatids.-— Symptoms. 

CHAPTER  V. 

Diseased  Appearances  of  the  Thyroid  Gland,  the  Larynx,  and  the 
parts  contained  in  the  Posterior  Mediastinum.  53 

Inflammation  of  the  thyroid  gland. — Bronchocele. — Scirrhus  of 
the  thyroid  gland. — The  thyroid  gland  converted  into  bone. — 
Larnyx. — The  cartilages  of  the  larnyx  converted  into  bone. — 
Ulcers  in  the  cavity  of  the  larnyx. — Diseased  appearances  of 
the  parts  contained  in  the  posterior  mediastinum. — Diseased 
appearances  of  the  trachea. — Inflammation  of  the  inner  mem- 
brane of  the  trachea — Appearances  of  the  trachea  in  the  croup. 
— Polypus — Trachea  scirrhous.— Rings  of  the  trachea  ossified. 
— Ulcer  of  the  trachea.— Diseased  appearances  of  the  oesopha- 
gus.— Spasmodic  stricture  of  the  oesophagus.— Stricture  from 
the  puckering  of  the  inner  membrane  of  the  oesophagus. — 
Stricture  attended  with  ulcer. — (Esophagus  cartilaginous. — 
Fungus  in  the  pharynx. — Scrofulous  swelling  in  the  pharynx. 
— Pouch  formed  at  the  lower  end  of  the  pharynx. — The  de- 
scending aorta  aneurysmal. — The  vena  azygos  varicose. — The 
vena  azygos  ruptured. — The  thoracic  duct  varicose. — Thoracic 
duct  obstructed. — Thoracic  duct  ruptured. — Absorbent  glands 
scrofulous. — Absorbent  glands  scirrhous. — Absorbent  glands 
bony. — Diseased  appearances  of  the  anterior  mediastinum. — 
Diseased  appearances  of  the  thymus  gland. — Symptoms. 

CHAPTER  VI. 

Diseased  appearances  within  the  Cavity  of  the  Abdomen.  77 

Ascites. — Chyle  in  the  cavity  of  the  peritonaeum. — Inflammation, 
of  the  peritonaeum. — Adhesions  in  the  cavity  of  the  abdomen. 
— Scrofulous  tumours  adhering  to  the  peritonaeum. — Cancer- 
ous tumours  adhering  to  the  peritonaeum.— Cartilaginous  ex- 
crescences growing  from  the  peritonaeum. — Steatomatous  tu- 
mours adhering  to  the  peritonaeum — Hydatids  in  the  abdo'men. 
— Air  in  the  cavity  of  the  abdomen. — Symptoms. 

CHAPTER  VII. 

Diseased  Appearances  of  the  Stomach.  88 


xvi  CONTENTS. 

Inflammation.— Appearances  in  hydrophobia.—Ulcers  in  the 
stomach. — Scirrhus  and  cancer  of  the  stomach. — Circumscribed 
scirriious  tumours  in  the  stomach. — Pouch  formed  in  the 
stomach. — Stricture  at  the  pylorus.— Fungous  tumours  ob- 
structing the  pylorus. — Stomach  much  contracted,  or  much 
enlarged — Stomach  distended  with  air. — Part  of  the  stomach 
disolved  by  the  gastric  juice — Fatty  tumours  in  the  stomach. 
—Calculi  in  the  stomach — Morbid  papillae  observed  in  the 

stomach — Small-pox   pustules  said  to   be  in  the  stomach 

Symptoms. 

CHAPTER  VIII. 

Diseased  Appearances  in  the  Intestines.  99 

Inflammation.— -Intus-susceptio. — Ruptures. — Hernia  congenita. 
— i-Scirrhus  and  cancer  of  the  intestines. — Diseased  change  of 
the  intestines  in  dysentery. — Thickened  folds  of  the  inner 
membrane  of  the  great  intestines. — Polypous  tumours. — A 
milt-like  tumour. — Piles.— Fistulae  in  ano.— The  rectum  ter- 
minating iu  a  cul-de-sac.— The  rectum  terminating  in  the 
bladder.— Worms.— Lumbricus  teres. — Tsenia  solium. — 
Tsenia  lata. — Ascaris. — Trichuris. — Air  accumulated  in  the 
intestines. — Bony  matter  in  the  intestines. — Projecting  ring 
formed  in  the  cavity  of  the  jejunum. — Concretions  in  the  in- 
testines.— Small-pox  pustules  said  to  be  in  the  intestines. — 
Mesentery  inflamed — Mesenteric  glands  scrofulous. — Mesen- 
teric  glands  cancerous. — Mesenteric  glands  earthy  or  bony. — 
Symptoms. 

CHAPTER  IX, 

Diseased  Appearances  of  the  Liver.  133 

Inflammation  of  the  membrane  of  the  liver. — Adhesions. — Coats 
of  the  liver  converted  into  cartilage. — Inflammation  of  the 
substance  of  the  liver. — Common  tubercle  of  the  liver. — 
Large  white  tubercle  of  the  liver.— -Soft  brown  tubercles  of 
the  liver. — Scrofulous  tubercles  of  the  liver. — Liver  flaccid 
with  reddish  tumours. — Liver  very  soft  in  its  substance. — 
Liver  very  hard  in  its  substance. — Hydatids. — Cysts  in  the 
liver  containing  an  earthy  matter. — Rupture  of  the  liver.— 
Worms  said  to  be  in  the  liver.— Symptoms. 


CONTENTS.  xvii 

CHAPTER  X. 

Diseased  Appearances  in  the  Gall-bladder.  150 

Inflammation  of  its  coats. — Adhesions. — Ulcers  in  the  gall- 
bladder.— Coats  of  the  gall-bladder  thickened,  and  hard  tuber- 
cles formed  in  them. — Coats  of  the  gall-bladder  bony— 
Dilatation  of  the  biliary  ducts. — Obliteration  of  the  biliary 
ducts.— A  preternatural  canal  of  communication  between  the 
gall-bladder  and  the  stomach. — Gall-stones. — Bile. — Gall- 
bladder distended  with  bile. — Hydatids  in  the  gall-bladder. — . 
The,  bladder  wanting. — Symptoms. 

CHAPTER  XL 

Diseased  Appearances  of  the  Spleen.  161 

Inflammation  of  the  coats  of  the  spleen — Adhesions — Coats  of 
the  spleen  cartilaginous. — Inflammation  of  the  substance  of 
the  spleen. — The  spleen  extremely  soft. — The  spleen  very- 
hard. — Tubercles  in  the  spleen. — Spleen  very  large — Hydatids 
in  the  spleen, — Stony  concretions  in  the  spleen. — The  spleen 
ruptured. — Several  small  spleens. — Spleen  said  to  be  wanting. 
— Symptoms. 

CHAPTER  XII. 

Diseased  Appearances  of  the  Pancreas.  169 

Abscesses  of  the  pancreas. — Pancreas  hard. — Calculi  of  the 
pancreas. — Steatomatous  tumours — Pancreas  wanting.-— 
Symptoms. 

CHAPTER  XIII. 

Diseased  Appearances  of  the  Kidneys  and  the  Renal  Capsules.  173 
Capsule  of  the  kidneys  inflamed. — Abscesses  of  the  kidneys. — 
Scrofulous  tubercles  in  the  kidneys — Kidneys  scirrhous. — 
State  of  the  kidneys  in  diabetes. — Kidneys  very  soft. — Hydatids 
of  the  kidneys. — Calculi  of  the  kidneys. — Kidneys  earthy  and 
bony. — Original  varieties  in  the  kidneys. — Diseased  appear- 
ances of  the  renal  capsules. — Abscess  in  the  renal  capsules. — 
Renal  capsules  scrofulous. — Symptoms. 

CHAPTER  XIV. 

Diseased  Appearances  of  the  Bladder.  184 

Inflammation  of  the  peritonaea!  covering. — Inflammation  of  the 

inner  membrane, — Ulcers, — Scirrhus  and   cancer.— Fungous 


xvui  CONTENTS. 

excrescences — Polypus  of  the  bladder. — Elongations  of  the 
inner  membrane. — Veins  of  the  inner  membrane  of  the  bladder 
enlarged  and  varicose. — Cysts  communicating  with  the  bladder. 
— Muscular  coat  thickened. — The  bladder  divided  into  two 
chambers. — Calculi. — Bladder  distended. — Bladder  contrac- 
ted.— The  anterior  part  of  the  bladder  wanting. — The  bladder 
and  the  rectum  communicating  from  mal -formation. — Part  of 
the  bladder  in  a  hernial  sack. — Symptoms. 

CHAPTER  XV. 

Diseased  Appearances  of  the  Vesiculae  Seminales.  203 

Vesiculse  seminaies  inflamed. — Vesiculae  seminales  scrofulous. 

Duels  of  the  vesiculae  seminales  terminating  in  a  cul-de-sac. — 

Vesiculae  seminales  very  small. — One  of  the  vesiculse  seminales 

wanting. — Vesiculae  seminales  scirrhous.— Symptoms. 

CHAPTER  XVI. 

Diseased  Appearances  of  the  Prostate  Gland.  206 

Abscess  in  the  prostate  gland. — Scrofula  of  the  prostate  gland. 

— Scirrhus  of  the  prostate  gland. — Calculi  in  the  ducts  of  the 

prostate  gland. — Ducts  of  the  prostate  gland  enlarged. — The 

prostate  gland  preternaturally  small. — Symptoms. 

CHAPTER  XVII. 

Diseased  Appearances  of  the  Urethra.  212 

Abscesses. — Fistulae. — Stone  in  the  cavity  of  the  membranous 
part  of  the  urethra. — Cowper's  glands  seldom  observed  to  be 
Diseased. — Inner  membrane  of  the  urethra  inflamed. — Ulcers 
in  the  urethra. — Stricture. — Caruncle. — Enlargement  of  the 
mucous  glands  of  the  urethra. — A  layer  of  earthy  matter  in 
the  urethra. — Preternatural  orifice  of  the  urethra. — Symptoms. 

CHAPTER  XVIII. 

Diseased  Appearances  of  the  Testicles  and  the  Spermatic  Chord.  2 1 8 

Hydrocele. — Hydatids. — Loose  cartilages  in  the  tunica  vaginalis 

testis. — Adhesions. — Testicle    inflamed. — Abscesses     of    the 

testicle. — Testicle    Scrofulous. — Testicle  enlarged  and  pulpy. 

— Scirrrhus  and  cancer  of  the  testicle. — Testicle  cartilaginous. 

1    — Testicle  bony. — A  cyst  adhering  to  a  testicle  containing  a 


CONTENTS,  xix 

vena  medinensis. — The  epididymis  ending  in  a  cul-de-sac.- — 
Stricture  of  the  vas  deferens. — Testicles  very  small,  and  wasted. 
— Spermatic  chord  scirrhous. — Veins  of  the  spermatic  chord 
varicose. — Water  accumulated  in  the  cellular  membrane  of 
the  spermatic  chord. — A  sack  containing  water  formed  in  the 
spermatic  chord. — Symptoms. 

CHAPTER  XIX. 

Diseased  Appearances  in  the  Female  Organs.  228 

Inflammation  of  the  uterus. — Malignant  ulcer  of  the  uterus. — 
Hardness  and  enlargement  of  the  uterus. — Tubercles  of  the 
uterus. — Polypus. — The  inversion  of  the  uterus.— Prolapsus 
uteri. — Stricture  in  the  cavity  of  the  uterus. — The  os  uteri 
contracted  and  closed  up. — Uterus  bony. — The  uterus  changed 
into  an  earthy  substance.— A  bony  mass  in  the  cavity  of  the 
uterus. — Stones  in  the  cavity  of  the  uterus. — Dead  foetus  in 
the  uterus  converted  into  an  earthy  mass. — Water  in  the 
cavity  of  the  uterus. — Hydatids  in  the  uterus. — Air  in  the 
uterus — Rupture  of  the  uterus. — Two  uteri Natural  varie- 
ties in  the  uterus. — Symptoms. 

CHAPTER  XX. 

Diseased  Appearances  of  the  Ovaria.  243 

Inflammation  of  the  peritonaeal  covering  of  the  ovaria. — Inflam- 
mation of  .the  substance  of  the  ovaria. — Enlargement  and 
hardness  of  the  ovaria. — Ovaria  enlarged  and  changed  into  a 
pulpy  substance.— Ovaria  scrofulous. — Dropsy  of  the  ovaria. 
— The  ovaria  changed  into  a  fatty  substance  with  hair  and  teeth. 
— A  foetus  in  the  ovarium. — Shrinking  of  the  ovaria. — One 
ovarium  or  both  wanting — Symptoms. 

CHAPTER  XXI. 

Diseased  Appearances  of  the  Fallopian  Tubes.  251 

Inflammation  of  the  Fallopian  tubes — Adhesions. — Dropsy  of 
the  Fallopian  tubes. — The  Fallopian  tubes  terminating  in  a 
cul-de-sac. — An  ovum  in  the  Fallopian  tube. — A  hard  tumour 
growing  from  a  Fallopian  tube. — Diseased  appearances  of  the 
round  ligaments, 


xx  CONTENTS. 

CHAPTER  XXII. 

Diseased  Appearances  of  the  Vagina.  256 

Inflammation  of  the  vagina — Adhesion  of  the  sides  of  the  vagina. 

— Ulcers  in  the  vagina. — Scirrhous  tumours  in  the  vagina 

Inversion  of  the  vagina. — The  vagina  very  short. — The  vagina 
widened — The  vagina  very  narrow.—Symptoms. 

CHAPTER  XXIII. 

.Diseased  and  Preternatural  Appearances  of  the  external  Parts.  26$; 
The  hymen  imperforated. — The  clitoris  enlarged. — The  nymphae 
enlarged.— The  external  labia  growing  together, 

CHAPTER  XXIV. 

Diseased  Appearances  of  the  Brain  and  its  Membranes.  265 

Inflammation  of  the  dura  mater. — Scrofulous  tumours  connected 
with  the  dura  maiei . — Spongy  tumours  growing  from  the  dura 
mater.— Bony  matter  formed  in  the  dura  mater. — Very  strong 
adhesion  of  the  dura  mater  to  the  cranium.— Diseased  appear- 
ances of  the  tunica  arachnoides.— -Veins  of  the  pia  mater  turgid 
with  blood. — The  pia  mater  inflamed.— Scrofulous  tumours 
adhering  to  the  pia  mater. — Air  in  the  vessels  of  the  pia  mater* 
— Hydatids — -A  part  of  the  pia  mater  bony. — Diseased  Ap 
pearances  in  the  substance  of  the  brain.— Inflammation.— - 
Abscesses. — Gangrene.— The  brain  very  soft. — The  brain  very 
firnl .—A  white  firm  substance  formed  in  the  brain. — Encysted 
tumours  and  Hydatids.-— Bony  tumours  pressing  upon  the  brain . 
• — Bony  ridges  irritating  the  brain. — Hdrocephalus. — Water  on 
the  surface  of  the  brain,  or  between  its  membranes.— Air 
between  the  membranes  of  the  brain  and  in  its  ventricles.— 
Blood  effused  or  extravasated. — Cavities  in  the  brain  containing 
a  serous  fluid. —  Aneurysm  of  the  internal  carotid  arteries  on 
the  side  of  the  sella  turcica. — Little  bags  in  the  plexus  choroides. 
— Round  tumours  adhering  to  the  plexus  choroides. — Earthy 
matter  in  the  pineal  gland— Pineal  Gland  said  to  be  scirrhous. 
— Water  in"  the  pineal  gland. — Diseased  appearances  of  the 
pituitary  gland. — Diseased  appearances  of  the  nerves.— Mai 
formations  of  the  brain.-— Symptoms- 


THE 

MORBID  ANATOMY 

OF 

SOME  OF  THE  MOST  IMPORTANT  PARTS 

OF  THE 

HUMAN  BODY. 


CHAPTER  I. 

DISEASED   APPEARANCES  OF    THE 
PERICARDIUM, 

Inflammation  of  the  Pericardium. 

THE  pericardium,  or  the  membrane  which  surrounds 
the  heart  like  a  bag,  and  is  reflected  upon  its  surface, 
giving  it  a  smooth  external  covering,  is  liable  to  inflam- 
mation. This  is  not  a  very  common  disease,  although  it 
happens  sufficiently  often  to  afford  frequent  opportunities 
of  examining  its  effects  after  death.  The  disease,  from 
its  nature^  cannot  be  confined  to  any  particular  periods 
of  life;  yet  from  what  I  have  seen,  I  should  believe  that 
it  takes  place  more  commonly  when  the  body  has  been 
for  some  time  in  its  adult  state,  than  either  in  childhood 
or  advanced  age. 

In  inflammation  of  the  pericardium,  the  membrane  is 
generally  thicker  than  in  its  natural  state,  and  is  also  a 
little  more  pulpy.  This  change  depends  upon  additional 

A 


matter  being  thrown  into  the  membrane  by  the  increased 
action  of  the  small  vessels  which  are  distributed  upon  it. 
It  is  also  crowded  with  a  very  unusual  number  of  minute 
vessels,  which  contain  florid  blood.  Upon  the  inside  of 
the  pericardium  there  is  a  layer  of  a  yellowish  pulpy 
matter,  which  commonly  does  not  adhere  firmly  to  it,  but 
may  be  easily  separated.  It  generally  extends  over  the 
whole  of  its  inner  surface,  and  varies  a  good  deal  in  its 
thickness.  In  some  instances  it  is  as  thin  as  a  wafer,  and 
in  others  as  thick  as  a  half-crown.  In  this  matter,  which 
is  lining  the  pericardium,  there  is  frequently  to  be  seen  a 
slight  red  appearance,  from  small  blood  vessels  which  are 
ramifying  through  it:  but  these  are  most  distinctly  detected 
by  filling  them  with  the  fine  injection.  They  are  some- 
times numerous,  and  may  be  clearly  traced  passing  from 
the  pericardium  into  the  pulpy  matter;  in  which  I  have 
also  seen  small  spots  of  florid  blood.  These  newly  formed 
vessels  afford  a  very  convincing  proof  of  this  extravasated 
matter  possessing  a  living  principle;  for  one  cannot  imagine 
that  blood  vessels  would  shoot  into,  and  form  a  number  of 
new  branches  in  a  substance  which  is  dead.*  Upon  its 
inner  surface,  this  matter  very  frequently  throws  out  little 
irregular  laminated  processes,  giving  the  appearance  of  a 
lace- work,  and  junctions  are  often  formed  between  that 
portion  of  it  lining  the  pericardium,  which  is  reflected  like 
a  bag,  and  that  other  portion  lying  upon  the  pericardium, 
which  is  the  immediate  covering  of  the  heart.  This  matter 
has  a  very  close  resemblance,  both  in  colour  and  structure, 
to  the  coagulable  lymph  of  the  blood,  and  is  probably 
nothing  else  than  this  substance  separated  from  the  blood  by 

*  This  is  an  argument  used  by  Mr.  Hunter,  in  suppport  of  the  living  princi- 
ple of  the  blood"  " 


a  particular  action  of  the  small  vessels  of  the  pericardium. 

At  the  same  time  that  this  layer  of  pulpy  matter  is 
formed  upon  the  inner  surface  of  the  pericardium,  there 
is  accumulated  in  its  cavity  more  or  less  of  a  brownish  or 
yellowish  fluid.  There  is  sometimes  only  a  few  ounces 
of  it;  at  other  times  more  than  a  pint.  In  it  are  floating 
loose  shreds  of  the  pulpy  matter  formerly  described,  and 
there  is  also  occasionally  some  mixture  of  pus.  This  fluid 
resembles  in  its  properties  the  serum  of  the  blood,  and 
has  commonly  been  considered  as  the  serum. 

Inflammation  of  the  pericardium  sometimes  advances 
to  form  pus,  although  rarely.  Of  this  I  have  seen  one  in- 
stance. The  pericardium  was  much  thickened,  was  in- 
flamed, and  lined  with  coagulable  lymph;  but  there  was 
no  sign  of  ulceration  in  any  part  of  it.  This  last  circum- 
stance will  be  more  particularly  taken  notice  of  when  we 
come  to  speak  of  the  diseased  appearances  of  the  pleura. 
The  pericardium  in  this  case,  contained  more  than  a  quart 
of  common  pus.  When  that  part  of  the  pericardium  is 
inflamed  which  forms  the  immediate  covering  of  the  heart, 
the  muscular  substance  of  the  latter  is  occasionally  in- 
flamed to  some  depth. 

When  the  pericardium,  or  any  other  membrane  lining 
a  circumscribed  cavity,  is  inflamed,  and  a  layer  of  coagula- 
ble lymph  is  formed  upon  its  surface,  a  peculiar  disposi- 
tion is  given  to  the  coagulable'  lymph  by  the  action  of  the 
small  vessels  which  pour  it  out.  This  peculiar  disposition 
is  its  tendency  to  immediate  coagulation.  As  soon  as  the 
coagulable  lymph  is  thrown  out  upon  an  inflamed  surface, 
one  must  suppose  that  it  immediately  coagulates.  If  it 
did  not  immediately  coagulate,  but  remained  for  some 
time  fluid,  as  in  the  spontaneous  separation  of  the  con- 


stituent  parts  of  the  blood  in  a  bason  after  common 
bleeding-,  then  the  coagulable  lymph  would  form  a  small 
cake  at  the  bottom  of  the  serum,  easily  moveable  from  one 
part  of  the  cavity  to  another,  and  would  not  form  a  layer 
adhering  to  the  surface  of  the  inflamed  membrane. 

The  serum  is  generally  in  a  much  larger  quantity,  than 
could  take  place  in  consequence  of  its  mere  spontaneous 
separation  from  the  coagulable  lymph  which  is  spread 
upon  the  surface  of  the  inflamed  membrane.  The  blood 
vessels,  therefore,  which  are  distributed  in  the  layer  of  the 
coagulable  lymph,  would  seem  to  pour  out  some  quantity 
of  serum.  While  the  inflammation  is  receding,  and  the 
coagulable  nymph  is  changing  into  adhesions,  the  serum 
is  generally  taken  up  from  the  cavity  ;  and  this  effect  must 
be  supposed  to  be  produced  by  the  action  of  absorbent 
vessels.  The  membrane  of  adhesions  must  therefore  have 
absorbent  vessels  belonging  to  it,  which  have  probably 
been  formed  by  the  elongation  or  growth  of  the  absorbents 
of  the  inflamed  membrane,  shooting  into  the  coagulable 
lymph. 

Besides  serum,  we  have  mentioned  that  pus  is  some- 
times found  in  an  inflamed  circumscribed  cavity.  When 
this  is  the  case,  it  seems  extremely  probable  that  the  small 
arteries,  distributed  in  the  layer  of  the  coagulable  lymph, 
have  poured  out  the  pus.  This,  I  believe,  has  not  hitherto 
been  thought  of;  but  it  is  difficult  to  conceive  under  these 
circumstances  any  other  source  from  whence  the  pus  is 
derived.  If  the  pus  be  supposed  to  be  formed  by  the  arte- 
ries which  ramify  in  the  inflamed  membrane  itself,  then  it 
must  transude  through  a  layer  of  coagulable  lymph,  which 
is  often  of  considerable  thickness,  before  it  accumulates 
in  the  cavity.  This,  however,  is  not  likely;  and  as  arteries 


pass  from  the  original  membrane  into  the  layer  of  the  co- 
agulable  lymph,  it  becomes  more  reasonable  to  suppose 
that  pus  is  formed  by  the  arteries  distributed  in  the  co- 
agulable  lymph,  than  in  the  original  membrane  itself. 

Adhesions  of  the  Pericardium  to  the  Heart. 

In  opening  dead  bodies,  adhesions  of  the  pericardium 
to  the  heart,  are  not  uncommonly  found.  The  adhesion  is 
sometimes  at  different  spots;  at  other  times  is  extended 
over  the  whole  surface.  It  either  consists  of  a  thin  mem- 
brane, or  of  a  more  solid  matter.  When  it  is  a  thin  mem- 
brane, it  resembles  exactly  the  common  cellular  membrane 
of  the  body;  and  when  the  matter  is  solid,  it  differs  onl}r 
a  little  from  the  coagulable  lymph  of  the  blootl,  recently 
poured  out  upon  an  inflamed  surface.  Whether  the  ad- 
hesion be  in  the  one  way  or  the  other,  the  matter  of  the 
adhesion  is  in  both  cases  capable  of  being  rendered  vas- 
cular by  injection.  The  adhesion  too  is  in  both  cases 
formed  from  the  pulpy  matter  formerly  explained,  for  I 
have  oftener  than  once  had  an  opportunity  of  tracing  its 
gradual  changes  into  each.  Such  adhesions  are  to  be 
considered  as  the  consequence  of  inflammation,  and  shew 
that  an  inflammation  of  the  pericardium  may  be  survived. 
They  connect  the  pericardium  in  different  cases,  more 
closely  or  loosely  to  the  surface  of  the  heart.  Where  the 
connection  is  close,  the  inflammation  has  probably  been 
more  recent,  and  where  it  is  loose,  the  inflammation  has 
probably  been  of  older  date,  so  that  time  has  been  given 
for  the  adhesions  to  be  elongated  by  the  motion  of  the  heart, 

Dropsy  of  the  Pericardium. 
This  disease  is  not  uncommon,  and  I  believe  is  most 


frequent  at  an  advanced  period  of  life.  I  have  seen  it, 
however,  in  persons  considerably  under  the  age  of  thirty; 
and  it  probably  also  happens  occasionally  in  childhood. 
I  have  seen  oftener  than  once,  both  anasarca  and  ascites  in 
children  under  twelve  years  old,  which  is  as  improbable 
as  the  accumulation  of  water  in  the  pericardium.  Water 
is  sometimes  found  accumulated  in  the  pericardium,  while 
there  is  none  in  any  other  cavity;  but  generally  it  is  ac- 
companied with  the  accumulation  of  water  in  the  other 
cavities  of  the  thorax. 

This  water  varies  a  good  deal  in  quantity,  amounting 
in  some  cases  hardly  to  two  ounces,  and  in  others  to  more 
than  a  pint.  Although  the  quantity  be  large  which  may 
happen  to  be  accumulated,  yet  the  pericardium  is  never 
very  much  stretched ;  but  it  always  appears  as  if  it  could 
contain  a  greater  quantity.  It  is  probable,  therefore,  that 
the  pericardium  may  really  grow  so  as  to  keep  pace  with 
the  accumulation ;  and  this  would  seem  to  be  necessary, 
in  order  that  the  heart  may  have  room  for  dilating  its 
several  cavities. 

The  fluid  which  is  accumulated,  is  of  a  brown  colour, 
having  a  darker  or  lighter  shade  in  different  cases,  and 
resembles  in  its  properties  the  serum  of  the  blood.  If  the 
person  should  happen  at  the  same  time  to  have  jaundice, 
then  the  fluid  has  a  yellow  tinge  from  the  bile.  It  has, 
however,  frequently  a  yellowish  colour,  like  the  serum, 
without  there  being  any  reason  to  suppose  that  bile  has 
been  circulating  with  the  blood. 

Scrofulous  Tumours  in  the,  Pericardium. 

1  had  once  an  opportunity  of  seeing  two  or  three 
scrofulous  tumours,  growing  within  the  cavity  of  the 


pericardium,  one  of  which  was  nearly  as  large  as  a  Walnut- 
They  consisted  of  a  white  soft  matter,  somewhat  re- 
sembling curd  or  new  cheese.  The  pericardium  is  a  very 
unusual  part  of  the  body  to  be  attacked  by  scrofula,  and 
therefore  this  must  be  considered  as  a  very  rare  appearance 
of  disease. 

The  Pericardium  almost  dry. 

I  have  twice  found  (and  it  has  been  seen  much  oftener 
by  an  anatomist,*  whose  authority  is  of  great  weight)  the 
pericardium  so  changed  as  to  resemble  a  common  ox's 
bladder  in  some  degree  dried;  or  like  a  common  peri- 
cardium which  has  been  for  some  time  exposed  to  the  air. 
As  the  thorax  and  abdomen  were  entire  in  both  cases,  no 
opening  whatever  having  been  made  into  either,  this 
effect  could  not  arise  from  evaporation.  Were  this 
capable  of  taking  place,  the  appearance  here  noticed, 
would  be  very  usual  in  examining  dead  bodies,  and  the 
internal  parts  generally  would  be  aifected  by  the  influence 
of  the  same  cause.  It  must  be  considered  therefore  as  the 
effect  of  a  process  which  was  going  on  during  life.  The 
cause  of  this  appearance  is  either  a  defect  in  the  action  of 
the  exhalent  vessels  of  the  pericardium,  so  that  the  fluid 
which  naturally  lubricates  this  part,  is  not  secreted  in  the 
proper  quantity:  or  it  is  an  increased  action  of  the  ab- 
sorbent vessels  of  the  pericardium,  by  which  the  lubri- 
cating fluid  is  taken  up  in  larger  proportion  than  it  is  de- 
posited by  the  exhalent  arteries. 


*  Mr.  Hunter. 


The.  Pericardium^  cartilaginous,  and  bony. 

A  portion  of  the  pericardium,  has  in  some  instances 
been  observed  to  be  converted  into  cartilage,"*  and  in 
others  into  bone,  f  but  both  of  these  changes  are  very  un- 
common. 

I  had  an  opportunity  lately  of  examining  an  instance 
of  the  latter  sort,  in  which  the  ossific  process  had  spread 
over  a  considerable  portion  of  the  pericardium.  A  carti- 
laginous state  of  the  pericardium  has  not  fallen  under  my 
own  observation. 

The  Pericardium  wanting. 

A  few  instances  have  occurred,  in  which  the  pericardium 
has  been  wanting,  from  a  defect  in  the  original  formation. 
When  this  deficiency  takes  place,  the  heart  appears  per- 
fectly bare  and  distinct  to  the  eye,  upon  removing  the 
sternum  and  the  cartilaginous  extremities  of  the  ribs.  The 
external  surface  of  the  different  cavities  and  blood  vessels 
of  the  heart  is  seen  as  distinctly  as  when  the  pericardium 
is  laid  open  in  the  natural  structure  of  these  parts.  A 
close  and  uniform  adhesion  of  the  pericardium  to  the 
heart  has  sometimes  been  mistaken  for  this  malformation, 
but  they  are  very  different  from  each  other.  When 
there  is  a  close  adhesion  of  the  pericardium  to  the  heart, 
the  external  surface  of  the  different  cavities  and  blood 
vessels  of  this  organ  does  not  come  into  view,  upon  re- 
moving the  sternum  and  a  part  of  the  ribs.  The  whole 
of  this  appearance  is  as  completely  hid  as  in  the  healthy 
structure.  It  is  only  when  the  adhesion  is  removed  by 
dissection  that  the  external  surface  of  the  heart  and  blood 

*  See  Morgagni  cle  Causis  et  Sr-dibus  Morborum,  Epist,  XXII.  Art.  1C 
•f  See  Ronctus,  Tom.  1.  p.  5R" 


dissection  that  the  external  surface  of  the  heart  and  blodd 
vessels  comes  into  view.  When  there  is  an  adhesion  of 
the  pericardium  to  the  heart,  this  membrane  adheres  at 
the  same  time  closely  to  the  tendinous  part  of  the  dia- 
phragm ;  but  when  there  is  an  original  want  of  the  peri- 
cardium,  the  heart  lies  loose  in  the  cavity  of  the  chest, 
having  no  connection  whatever  with  the  diaphragm, 
and  is  covered  by  the  pleura,  like  the  lungs.  I  have  had 
an  opportunity  of  seeing  once  an  example  of  a  want  of 
the  pericardium,  and  have  described  it  in  the  Medical 
and  Chirurgical  Transactions.* 


SYMPTOMS. 

The  symptoms  attending  inflammation  of  the  peri- 
cardium, cannot  be  distinguished  in  practice  from  in- 
flammation of  the  substance  of  the  heart.  Wherever 
the  inflammation  of  the  pericardium  is  violent,  the  muscu- 
lar substance  of  the  heart  is  inflamed  to  some  depth,  and 
therefore  the  inflammations  of  both  parts  are  often  blended 
together.  The  symptoms,  which  have  been  observed, 
are  Symptomatic  Fever;  pain  in  the  region  of  the  heart; 
most  commonly,  but  not  constantly,  palpitations,  and 
an  irregular  pulse:  cough;  difficulty  of  breathing;  and 
sometimes  syncope. 

*  See  page  91,  Vol.  I. 

-T— *^*t    £Rh    tt^^^m 

B 


10 

*  The  symptom's  attending  the  adhesions  of  the  peri- 
cardium to  the  heart  are  not  so  clearly  marked  as  to  be 
well  distinguished  in  practice.  When  the  adhesions 
are  partial  and  long,  so  that  the  heart  can  enjoy  a  free 
play  within  the  pericardium,  probably  little  or  no  in- 
convenience is  felt.  But  when  the  adhesions  are  close, 
and  extend  generally  over  the  surface  of  the  heart,  the 
following  symptoms  have  been  observed,  viz.  a  sense  of 
oppression,  and  sometimes  of  pain  in  the  situation  of 
the  heart;  a  pulse  often  irregular  and  intermittent ;  diffi- 
culty of  breathing,  and  sometimes  a  dry  cough. 


When  water  is  accumulated  in  the  pericardium,  the 
symptoms  are  found  to  resemble  very  much  those  be- 
longing to  hydrothorax,  and  have  not  been  clearly  dis- 
tinguished from  them  by  authors.  These  symptoms  will 
be  afterwards  mentioned  when  we  come  to  hydrothorax. 
It  may  perhaps  serve  as  some  imperfect  ground  of  dis- 
tinction between  the  two  diseases,  that  the  feeling  of 
oppression  is  more  accurately  confined  to  the  situation  of 
the  heart,  and  the  heart  is  more  disturbed  in  its  functions, 
in  dropsy  of  the  pericardium,  than  in  hydrothorax.  It 
ought  at  the  same  time  to  be  remarked,  that  the  two 
diseases  are  often  blended ;  in  which  case,  these  grounds 
of  distinction  cannot  be  applied. 


The  case  of  scrofulous  tumours  growing  upon  the 
inside  of  the  pericardium,  which  I  have  described,  was 
combined  with  tubercles  of  the  lungs;  and  the  person 


•. 

died  with  the  common  symptoms  of  pulmonary  con- 
sumption. Nothing  occurred  which  led  to  any  suspicion 
of  a  disease  in  the  pericardium.  It  is  reasonable  to  sup- 
pose, that  when  scrofulous  tumours  grow  in  the  peri- 
cardium9  there  will  hardly  be  any  inconvenience  felt  while 
they  are  small ;  but  when  they  enlarge  very  much  in  size, 
they  will  necessarily  prevent  the  full  dilatation  of  the 
heart,  and  disturb  its  functions.  This,  however,  will 
probably  be  very  difficult  to  be  distinguished  from  the 
disturbance  produced  by  other  causes,  which  must  in 
the  same  manner  impede  the  free  action  of  the  heart;  as, 
for  instance,  the  accumulation  of  water  in  the  pericardium,, 


The   symptoms  produced  by  a  defect  of  the  lubri- 
cating fluid  in  the  pericardium  are  at  present  unknown. 


12 

*' 


CHAPTER  II. 

DISEASED   APPEARANCES  OF   THE   HEART. 

Inflammation  of  the  Heart. 

INFLAMMATION  of  the  substance  of  the  heart  is  a  rare 
disease,  and  is  most  commonly  connected  with  an  in- 
flammation of  the  pericardium.  When  the  pericardium 
covering  its  surface  is  inflamed,  the  inflammation  some- 
times passes  a  little  way  into  the  substance  of  the  heart. 
That  part  of  it  becomes  much  more  crowded  with  small 
vessels  than  in  its  natural  state,  and  sometimes  are  to  be 
seen  in  it  a  few  spots  of  extravasated  blood.  The  sub- 
stance of  the  heart  may  however  be  inflamed,  without 
inflammation  of  the  pericardium.  I  recollect  an  instance 
of  this  sort,  where  no  marks  of  inflammation  could  be 
observed  in  that  membrane,  but  where  there  was  a  little 
more  water  than  usual  in  its  cavity. 

Authors  have  mentioned  cases  of  abscesses  and  ulcers* 
of  the  heart,  but  these  I  am  persuaded  are  extremely 
rare.  It  happens  still  more  rarely  that  the  heart  becomes 
mortified,  although  this  diseased  state  of  it  has  also  been 
observed.! 

White  Spot  upon  the  Surface  of  the  Heart. 

In  opening  dead  bodies,  there  is  very  often  to  be  seen 

• 

*  Vid.  Morgagni,  Epist.  XXV.  Artie.  17.  Vid.  Bonet.  Tom.  I.  p.  849;  and 
also  Lieutaud,  Tom.  II.  p.  27. 
tVid.  Lieutaud,  Tom.  II,  p.  33 


13 

upon  the  surface  of  the  heart,  a  white  opaque  spot  like 
a  thickening  of  the  pericardium.  This  is  sometimes 
not  broader  than  a  sixpence;  at  other  times  as  broad  as 
a  crown-piece.  It  is  most  commonly  on  the  surface  of 
the  right  ventricle,  and  is  rarely  to  be  seen  either  on  the 
surface  of  the  left  ventricle,  or  of  the  auricles,  although 
it  is  occasionally  on  both. 

It  consists  of  an  adventitious  membrane,  formed  on  a 
portion  of  the  pericardium  which  covers  the  heart,  and 
may  easily  be  dissected  off,  so  as  to  leave  the  pericardium 
entire.  It  is  an  appearance,  I  believe,  of  no  consequence 
whatever,  and  is  so  very  common,  that  it  can  hardly  be 
considered  a^  a  disease, 

Polypus. 

This  has  been  considered  by  the  older  anatomists,  as 
a  very  common  and  a  very  fatal  disease.  By  many  of 
the  moderns  it  has  been  rejected  as  a  disease  altogether. 
It  consists  of  a  mass  of  coagulable  lymph,  which  fills  up 
some  of  the  large  cavities  of  the  heart,  particularly  the 
ventricles,  and  extends  into  the  neighbouring  large  vessels. 

The  coagulable  lymph  is  of  a  yellowish  white  colour, 
sometimes  of  a  yellow  colour,  and  has  considerable  firm- 
ness. It  fills  up  the  cavity  completely,  or  nearly  so,  in 
which  it  is  found;  and  in  the  ventricles  it  shoots  out 
processes  among  the  fasciculi  of  the  muscular  fibres. 
From  this  circumstance  probably  it  has  derived  its  name. 
It  also  extends  into  the  larger  arteries  which  arise  from 
the  ventricles,  and  is  often  moulded  to  the  shape  of  the 
semi-lunar  valves  at  their  origin.  The  examples  of  this 
appearance  which  it  has  occurred  to  me  to  observe,  have 
been  chiefly  in  preparations,  and  had  undoubtedly  taken 


14 

place  after  death.  In  order  that  the  circulation  may  be 
carried  on,  it  is  necessary  that  the  cavities  of  the  heart 
be  free  for  the  transmission  of  blood;  and  if  any  one  of 
its  cavities  should  be  plugged  up,  the  circulation  would 
necessarily  be  stopped  altogether.  A  polypus,  however, 
plugs  up  the  cavity  of  the  heart  in  which  it  is  formed  so 
entirely,  as  to  prevent  the  circulation.  It  may  be  said, 
perhaps,  that  polypi  are  formed  gradually,  and  that  the 
circulation  is  carried  on  for  some  time,  although  very 
imperfectly.  In  by  much  the  greater  number  of  polypi, 
however,  when  examined,  there  is  the  same  sort  of  ap- 
pearance throughout  their  whole  substance;  which  shews 
that  the  whole  coagulum  had  been  formed  at  the  same 
time.  These  circumstances  seem  to  contradict  strongly 
the  opinion,  that  polypi  in  general  are  formed  during 
life.  When  polypi  are  formed,  I  believe  that  the  co- 
agulation of  the  blood  does  not  take  place  very  quickly 
after  death.  They  are  without  any  admixture  of  the 
red  globules  of  blood,  and  therefore  the  blood  has  been 
sufficiently  long  in  coagulating  to  allow  the  globules  to 
separate  from  the  other  parts,  in  consequence  of  their 
greater  specific  gravity.* 

The  ordinary  coagulation  of  the  blood,  which  com- 
monly do  not  fill  up  very  fully  the  cavities  of  the  heart 
(although  instances  occasionally  occur  of  this  sort)  take 
place  pretty  soon  after  death,  because  the  red  particles 

*  In  some  instances,  a  coagulum  of  blood  has  been  found,  of  a  laminated 
texture,  in  such  parts  of  the  heart  as  are  most  remote  from  the  direct  current 
of  the  circulation.  This  laminated  texture  shews  that  the  coagulation  had 
taken  place  during  life,  and  in  a  gradual  manner.  Two  cases  of  this  kind  have 
been  observed  by  Mr.  Brodie,  who  is  well  known  to  the  public,  as  an  ex- 
cellent anatomist  and  physiologist.  Such  cases  of  coagulation  are  much  less 
complete  than  those  which  have  been  generally  called  polypi,  and  which  filj 
up  entirely  one  or  more  of  the  large  cavities  of  the  heart. 


15 

of  the  blood  are  generally  arrested  in  the  coagulum.  It 
may  be  worth  while  to  remark,  that  there  is  sometimes 
found  a  portion  of  a  coagulum  in  one  of  the  ventricles  of 
a  yellow  colour,  and  with  an  oily  appearance,  so  as  to 
resemble  exactly  fat.  There  is,  however,  no  admixture 
of  oil  in  it,  and  it  possesses  all  the  ordinary  properties  of 
the  coagulable  lymph.  The  yellow  colour  of  a  coagulum, 
sometimes  depends  on  a  portion  of  the  bile  having  cir- 
culated with  the  blood  during  life,  as  in  cases  of  jaundice; 
but  it  takes  place  also  when  there  is  no  reason  to  suppose 
that  bile  is  mixed  with  the  blood. 

Aneurysm  of  the  Heart. 

It  sometimes  happens,  although  I  believe  very  rarely, 
that  the  heart  becomes  aneurysmal.  This  disease  consists 
in  a  part  of  it  being  dilated  into  a  pouch,  which  is  com- 
monly more  or  less  filled  with  coagulated  blood.  Of  this 
disease  I  have  only  seen  one  instance.  The  apex  of  the 
left  ventricle  was  dilated  into  a  pouch  targe  enough  to 
contain  a  small  orange,  was  much  thinner  than  in  the 
healthy  structure,  and  was  lined  with  a  thick  white  opaque 
membrane.  There  was  hardly  contained  in  it  any 
coagulated  blood;  but  the  quantity  of  the  coagulated 
blood,  in  an  aneurysm,  depends  commonly  on  the  size 
of  the  bag. 

This  disease  most  probably  arose  from  the  muscular 
structure  at  the  apex  of  the  ventricle  having  become 
weaker  than  in  any  other  part,  so  that  when  the  ventricle 
contracted  upon  the  blood,  it  was  pushed  against  the 
weakened  part,  which  was  not  fully  able  to  resist  its  im- 
petus, and  therefore  was  gradually  dilated.  Had  the 
strength  of  the  apex  of  the  left  ventricle  been  in  due  pro 


id 

portion  to  that  of  the  other  parts,  it  would  seem  impossi- 
ble  that  the  aneurysmal  swelling  should  ever  have  taken 
place. 

Aneuyrism  of  the  Arch  of  the  Aorta. 

The  most  frequent  situation  of  aneurysm  within  the 
cavity  of  the  thorax,  is  at  the  arch  of  the  aorta.  In  this 
disease  the  arch  of  the  aorta  is  much  enlarged  beyond 
its  usual  size,  sometimes  forming  an  uniform  tumour; 
sometimes  a  large  swelling,  which  arises  out  of  the  arch 
of  the  aorta  by  a  neck  or  narrower  portion;  and  sometimes 
smaller  swellings  arise  out  of  the  larger  one.  Where  the 
swelling  is  uniform  in  its  shape,  there  is  reason  to  believe 
that  there  has  been  a  considerable  dilatation  of  all  the 
coats  of  the  artery.  Where  the  swelling  arises  from  the 
arch  of  the  aorta  by  a  neck  or  narrower  portion,  the  iqner 
and  middle  coat  of  the  artery  have  been  burst  or  ulce- 
rated, and  a  dilatation  takes  place  in  the  outer  coat,  which 
is  strengthened  by  the  condensation  of  the  parts  immedi- 
ately surrounding  it.* 

The  coats  of  the  artery,  both  at  the  place  where  the 
aneurysm  is  formed,  and  near  it,  are  considerably  altered 
from  their  natural  structure.  They  are  more  readily 
divisible  into  different  layers,  than  where  the  artery  is 
sound,  and  spots  of  bony  matter  are  often  formed  in  them. 
These  spots  are  frequently  of  a  yellowish  colour,  and  are 
formed  either  in  the  internal  membrane  of  the  artery,  or 
immediately  behind  it. 

The  coats  of  the  artery  in  the  neighbourhood  of  the 
aneurysm,  are  often  found  to  be  very  irregular  in  their 

*  See  Scarpa's  well  known  work  upon  aneurysm,  and  an  excellent  treatise 
on  the  Diseases  of  Arteries  and  Veins,  by  Mr.  Hodgson  in  several  passage?. 


17 

texture,  being  in  some  places  transparent  and  thin,  in 
others  thick  and  opaque;  and  there  is  sometimes  the  ap- 
pearance of  a  double  internal  membrane.  The  same  sort 
of  structure  is  also  sometimes  to  be  found  in  the  coats  of 
the  aneurysm  itself.  The  arteries  near  an  aneurysm  are  dis- 
eased to  a  greater  or  less  extent  in  differeift  persons;  but  I  do 
not  recollect  one  instance  in  which  they  were  totally  free 
from  disease. 

The  disease  sometimes  ends  fatally ,  by  the  enlarged 
artery  bursting,  and  the  blood  escaping  into  the  cavity  of 
the  pericardium;  but  it  often  has  a  further  progress;  the 
swelling  of  the  aneurysm  gradually  increases,  till  at  length 
it  presses  against  the  sternum,  and  the  cartilaginous  ex- 
tremities of  some  of  the  ribs.  This  pressure  occasions 
a  portion  of  the  sternum  and  of  the  ribs  to  be  absorbed, 
and  the  tumour  is  thereby  perceived  externally.  The 
absorption  of  the  sternum  and  ribs  goes  on  very  gradually, 
and  is  not  accompanied  with  the  formation  of  pus.  The 
tumour  gradually  increases  in  size,  till  perhaps  it  is 
as  large  as  a  child's  head  at  birth ;  a  part  of  the  skin  be- 
comes in  some  measure  dead,  and  cracks  from  distention 
at  the  highest  point  of  the  tumour;  a  portion  of  the 
coagulated  blood  is  forced  out  by  the  impetus  of  the 
circulation,  and  the  person,  in  general,  is  cut  off  in- 
stantaneously. The  blood  sometimes  oozes  out  slowly, 
and  the  person  sinks  gradually  under  its  loss. 

Aneurysms  at  the  arch  of  the  aorta,  as  well  as  in  every 
other  part  of  the  arterial  system,  arise  generally  from  the 
coats  of  the  artery  being  previously  diseased,  which  are 
thereby  unable  to  resist  sufficiently  the  impetus  of  blood 
that  strikes  against  them.  This  is  obvious,  both  from 


18 

the  diseased  structure  of  the  coats  of  an  aneurysm  Itself,, 
and  of  the  artery  in  its  neighbourhood. 

I  have  also  found  very  frequently  diseased  appearances 
in  the  arch  of  the  aorta,  which  had  not  advanced  far 
enough  to  produce  aneurysm.  These  are  white  or  yellow- 
ish opaque  spots?  which  present  themselves  to  view  in 
looking  upon  the  inner  surface  of  the  artery,  and  often 
consist  of  a  curdy  or  atheromatous  matter  which  is 
placed  between  the  middle  and  inner  coat.  Under  such 
circumstances  these  coats  of  the  artery  are  more  easily 
separable  from  each  other  than  in  the  healthy  state. 

The  reason  why  aneurysms  take  place  more  frequently 
in  the  arch  of  trie  aorta,  than  in  any  other  part  of  the 
arterial  system,  is  its  curvature,  which  exposes  it  to  the 
full  impetus  of  the  blood  propelled  by  the  strength  of 
the  left  ventricle.  Aneurysms  hardly  ever  happen  in  the 
pulmonary  artery,  because  there  is  no  arch  formed  by 
the  pulmonary  artery,  and  the  blood  readily  passes  by 
two  large  branches  into  the  substance  of  the  lungs. 

Aneurysms  in  the  arch  of  the  aorta,  as  well  as  in  every 
other  part  of  the  arterial  system,  happen  much  more 
rarely  in  women  than  in  men.  This  arises  from  two 
causes.  The  one  is,  that  women,  from  their  sedentary 
life  and  temperance,  are  less  liable  to  an  increased  impetus 
of  the  blood,  occasioned  by  excited  circulation;  the  other 
is,  that  the  arteries  in  this  sex  appear  to  be  less  liable  to 
these  diseased  alterations  of  structure,  which  predispose 
to  aneurysm. 

Ossification  of  the  Coronary  Arteries  of  the  Heart. 

The  coronary  arteries  are  occasionally  ossified  in  a 
greater  or  less  degree.  This  state  of  them  is,  I  believe? 
generally  accompanied  with  ossified  portions  of  the  aorta 


at  its  origin,  and  sometimes  with  osssification  of  the  semi- 
lunar  valves. 

s~ 

Ossification  of  the  Semi-lunar  Valves. 

The  three  semi-lunar  valves  at  the  origin  of  the  aorta 
are  often  found  diseased.  The  disease  very  commonly 
consists  in  the  deposition  of  a  bony  or  earthy  matter,  and 
would  seem  to  be  formed  by  a  morbid  action  of  some 
very  minute  vessels  which  are  distributed  through  the 
substance  of  the  valves.  These  vessels  are  so  small,  as 
not  to  contain,  in  their  natural  state,  the  red  globules  of 
the  blood. 

Similar  valves  at  the  origin  of  the  pulmonary  artery 
are  occasionally  more  or  less  ossified,  but  by  no  means 
so  frequently  as  those  at  the  origin  of  the  aorta.  This 
probably  depends  upon  their  partaking  of  the  same  dis- 
position with  the  pulmonary  artery  itself,  the  coats  of  which 
are  much  less  subject  to  ossification  than  the  coats  of  the 
aorta.  When  the  mass  of  ossification  in  these  valves  is  large, 
the  aperture  at  the  origin  of  these  arteries  becomes  pro- 
portionably  narrowed,  and  there  is  much  more  difficulty 
in  the  blood  being  propelled  into  them  by  the  ventricles. 
In  consequence  of  this  impediment,  the  ventricles  become 
considerably  enlarged  in  their  size,  and  this  change,  for 
a  reason  lately  given,  is  more  apt  to  take  place  from  this 
cause,  in  the  left  than  the  right  ventricle. 

Semi-lunar  Valves  thick  and  opaque. 

It  frequently  happens  that  the  semi-lunar  valves  are 
considerably  thickened,  and  of  an  opaque  white  colour  ,- 
in  this  case,  the  coats  of  the  artery  in  the  neighbourhood, 
I  believe,  are  commonly  thickened  and  diseased. 


20 

When  the  semi-lunar  valves  have  undergone  this 
change,  the  communication  between  the  ventricles  and 
the  two  large  arteries  must  also  be  somewhat  narrowed, 
and  their  office,  as  valves,  must  be  more  or  less  impaired. 
Neither  of  these  effects,  however,  will  take  place  in  the 
same  degree,  as  when  there  is  a  considerable  deposition 
in  them  of  osseous  matter. 

Rupture  of  the  Valves. 

There  is  a  preparation  in  Dr.  Hunter's  collection, 
shewing  one  of  the  semi-lunar  valves  to  have  become 
thickened,  and  to  have  been  ruptured  to  a  considerable 
extent.  It  is  very  rare  that  such  an  occurrence  happens, 
and  in  the  present  instance  the  rupture  was  so  large,  that 
I  believe  it  must  have  proved  almost  immediately  fatal. 

Valves  between  the  Auricles  and  the  Ventricles  ossified. 

The  valvular  apparatus  between  the  auricles  and 
ventricles,  is  liable  to  the  formation  of  bony  and  earthy 
matter  in  it,  in  the  same  manner  as  the  valves  which  are 
situated  at  the  origin  of  the  two  large  arteries,  more 
especially  of  the  aorta,  but  by  no  means  so  frequently. 
What  this  depends  upon,  it  is  very  difficult  to  determine. 
These  valves  may  perhaps  be  considered  as  belonging 
more  to  the  venal  than  the  arterial  system,  and  it  is  certain 
that  ossification  takes  place  very  seldom  in  veins,  although 
very  often  in  arteries. 

The  quantity  of  bony  matter  deposited  in  these  valves 
is  often  very  considerable,  and  of  an  irregular  form.  The 
aperture  between  the  auricles  and  ventricles  becomes 
thereby  narrowed,  and  the  valves  have  their  mobility  more 
or  less  impaired. 


The  same  Valves  thick  and  opaque. 

The  valvular  apparatus  between  the  auricles  and 
ventricles  is  also  occasionally  thickened,  having  lost  all 
its  transparency,  and  having  an  opaque  white  colour. 
The  chordae  tendineas  likewise  become  thicker  than 
natural;  and  the  internal  membrane  lining  the  ventricles 
is  frequently  at  the  same  time  a  good  deal  thickened,  ap- 
pearing like  a  firm  white  membrane.  When  these  valves 
have  been  for  a  long  time  either  very  much  ossified,  or 
thickened,  the  auricles  of  the  heart  are  often  found  con- 
siderably enlarged  beyond  their  usual  size. 

I  have  also  seen  the  valvular  apparatus  between  the 
auricle  and  the  ventricle,  in  a  state  of  inflammation,  and 
covered  with  a  layer  of  coagulable  lymph :  but  this  I  be- 
lieve to  be  very  uncommon. 

Rupture  of  the  Heart. 

It  sometimes  happens,  and  I  believe  chiefly  in  those 
who  are  advanced  in  life,  that  the  heart  at  some  part  be- 
comes thinner,  and  upon  any  great  exertion  bursts.  The 
blood  escapes  into  the  cavity  of  the  pericardium,  and  the 
person  is  instantly  destroyed. 

Of  this  accident  I  have  seen  one  instance  only ;  but  have 
heard  from  the  best  authority  of  another.  They  both 
happened  to  men;  and  I  mention  this  circumstance,  be- 
cause men  appear  to  be  more  subject  to  diseases  of  the 
heart  and  blood  vessels  than  women.  It  is  probable 
that  persons  dying  from  this  cause  have,  on  account  of 
the  suddenness  of  their  death,  been  supposed  to  die  of 
apoplexy. 


Blood  in  the  Pericardium,  -without  a  Rupture  of  the  Heart. 

Cases  have  occurred,  although  very  rarely,  in  which  a 
large  quantity  of  blood  has  been  accumulated  in  the  cavity 
of  the  pericardium,  but  where  no  rupture  could  be  dis- 
cove^ed  after  the  most  diligent  search,  either  in  the  heart 
itself,  or  in  any  of  its  vessels.  This  appears  very  wonder- 
ful, and  not  at  all  what  any  person  would  expect  a  priori. 
Upon  the  supposition  of  there  being  no  rupture,  two 
conjectures  have  occurred  to  me  about  the  the  manner 
in  which  such  an  effect  may  have  taken  place,  and  they  are 
both  attended  with  considerable  difficulty. 

The  one  is  that  the  vessels  upon  the  surface  of  the 
heart,  may  have  lost  a  part  of  the  compactness  of  their 
texture,  so  that  the  blood  may  have  escaped  through  their 
coats  by  transudation.  The  other  is,  that  blood  may  have 
been  poured  out  by  the  extremities  of  the  small  vessels 
opening  upon  the  surface,  of  that  portion  chiefly  of  the 
pericardium  which  forms  the  immediate  covering  of  the 
heart,  from  their  orifices  having  been  to  a  very  uncom- 
mon degree  relaxed.* 

Malformations  of  the  Heart. 

It  also  happens,  although  I  believe  very  rarely  that  a 
heart  is  so  imperfectly  formed  as  to  allow  of  life  being 
continued  for  some  length  of  time,  in  a  very  uncomfortable 
state,  but  to  be  ultimately  the  cause  of  death.  There  are 
two  cases  of  this  sort  described  by  the  late  Dr.  Hunter,  f 
and  there  is  one  specimen  of  this  malformation  preserved 

*See  Med.   Observations,  Vol.   4.   p.    330.    Memoirs  of   Med.    Society, 
Vol.  1.  p.  238. 
fVid.  Medical  Observations,  Vol.  6.  p.  291. 


23 

In  his  collection.  The  malformation  preserved  in  the 
collection,  consists  in  the  right  ventricle  of  the  heart  being 
extremely  small,  and  the  pulmonary  artery  being  very 
small  also  which  arises  from  it.  At  its  origin  from  the 
right  ventricle  it  is  completely  impervious.  The  ductus 
arteriosus  is  open,  but  forms  likewise  a  small  canal,  and 
terminates  in  the  left  branch  of  the  pulmonary  artery. 
The  right  auricle  is  larger  than  it  naturally  is,  from  the 
frequent  accumulation  of  blood  in  it;  and  the  communi- 
cation between  the  two  auricles,  by  means  of  the  foramen 
ovale,  is  much  larger  than  usual.  The  child  in  whom 
this  malformation  was  found,  had  its  skin  of  a  very  dark 
colour,  and  had  very  laborious  respiration,  with  violent 
action  of  the  heart.  It  lived  only  thirteen  days. 


In  another  case  related  by  Dr.  Hunter,  the  pulmonary 
artery  was  very  small,  especially  at  its  origin,  and  there 
was  a  deficiency  in  the  septum  cordis,  at  the  basis  of  the 
heart,  large  enough  to  allow  a  small  thumb  to  pass  through 
it.  The  person  in  whom  this  malformation  of  the  heart 
was  found,  lived  about  thirteen  years.  He  never  had  a 
fresh  complexion,  but  it  was  always  dark,  or  tending  to 
black.  He  was  often  seized  with  fits,  especially  when 
there  was  any  hurry  upon  his  spirits,  or  there  had  been 
any  brisk  motion  of  his  body. 

It  is  obvious  that  in  these  deviations  from  the  natural 
structure,  a  small  quantity  of  blood  only  can  pass  through 
the  lungs  to  receive  the  benefit  of  respiration,  and  that 
this  will  be  more  or  less  according  to  the  degree  of  the 
deviation.  The  blood  will  from  this  cause  be  of  a  dark 


24 

colour,  as  it  is  well  known  that  it  receives  the  florid  hue 
from  the  influence  of  the  air  upon  it  in  the  lungs.  Hence 
the  colour  of  the  skin  must  be  necessarily  dtirk,  and  this 
will  be  increased  when  the  blood  is  accumulated  more 
than  usual  in  the  veins.  It  is  natural  to  think  that  in  such 
structures  of  the  heart,  the  circulation  will  be  carried  on 
with  much  more  difficulty  when  it  is  excited  beyond  its 
usual  standard.  This  may  even  be  supposed  to  be  in- 
creased to  such  a  degree  as  to  produce  fits,  which  hap- 
pened in  one  of  the  cases. 


There  is  an  example  also  in  Dr.  Hunter's  collection  of 
<\  heart  from  a  child,  which  had  a  hole  in  the  septum 
ventriculorem  at  the  basis  of  the  heart,  large  enough  to 
allow  a  goose  quill  readily  to  pass  through  it.  The  child 
was  still-born  at  six  months,  and  the  hole  in  the  septum 
evidently  arose  from  original  malformation.  This  too  is 
described  by  Dr.  Hunter  in  the  sixth  volume  of  the 
Medical  Observations.  An  instance  somewhat  similar  to 
this  has  been  published  by  Dr.  Pulteney,  in  the  third 
volume  of  the  Medical  Transactions;  the  person  to  whom 
this  monstrosity  belonged,  lived  to  near  fourteen  years 
of  age. 


A  very  singular  malformation  of  the  heart,  in  a  child 
about  two  months  old,  came  some  time  ago  into  my 
possession,  which  I  shall  describe  in  this  place.  The 
aorta  in  this  heart  arose  out  of  the  right  ventricle,  and  the 
pulmonary  artery  out  of  the  left.  There  was  no  comuni- 
cation  between  the  one  vessel  and  the  other,  except  through 


25 

the  small  remains  of  the  ductus  arteriosus,  which  was 
just  large  enough  to  admit  a  crow  quill.  The  foramen 
ovale  was  a  little  more  closed  than  in  a  child  newly  born. 
The  heart  was  of  the  common  size  for  a  child  of  two 
months  old,  and,  except  for  the  circumstances  which  have 
been  stated,  had  nothing  remarkable  in  its  structure.  In 
this  child  a  florid  blood  must  have  been  always  circulating 
between  the  lungs  and  the  left  side  of  the  heart,  except 
for  the  admixture  of  the  dark  blood  which  passed  through 
the  small  communication  of  the  foramen  ovale;  and  a 
dark  blood  must  have  been  always  circulating  between 
the  right  side  of  the  heart  and  the  general  mass  of  the 
body,  except  for  the  very  small  quantity  of  florid  blood 
which  passed  into  the  aorta  by  the  remains  of  the  ductus 
arteriosus.  Life  must,  therefore,  have  been  supported 
for  a  very  considerable  length  of  time  with  hardly  any 
florid  blood  distributed  over  the  body.  I  regret  ex- 
tremely that  I  have  only  been  able  to  collect  a  very  im- 
perfect account  of  the  child  when  alive.  The  child  had 
a  most  unusually  livid  skin,  which  arose  from  the  very 
small  proportion  of  the  florid  blood  in  the  general  circu- 
lation. The  surface  of  the  child's  body  felt  colder  than 
that  of  a  child  properly  formed  and  in  good  health;  the 
respiration  was  natural.  When  any  similar  malformation 
shall  occur,  it  could  be  wished  that  the  heat  of  the  surface 
of  the  body,  and  of  the  internal  parts,  were  measured 
accurately  by  a  thermometer.  The  heat  of  the  internal 
parts  will  be  most  conveniently  measured  by  putting  a 
thermometer  into  the  rectum.* 


*  This  very  singular  malformation  of  the  heart  was  given  to  me  by  Dr. 
William  Hyde  Wollaston,  who  look  much  trouble  in  endeavouring  to  collect 
information  about  the  child,  but  without  the  desired  success. 

D 


Heart  enlarged. 

The  heart  is  not  unfrequently  found  enlarged.     This 
may  occur  in  one  or  two  of  the  cavities,  or  may  extend 
to  all  the  cavities  of  the  heart.     This  change  will  some- 
times take  place  in  a  small  degree,  and  sometimes  the 
heart  is  enlarged  to  twice  or  thrice  its  natural  size.     The 
muscular  parietes  of  the  heart  are  sometimes  thickened 
along  with  this  enlargement,  but  more  commonly  they 
are  as  thin,  or  even  thinner  than  in  the  healthy  structure. 
This  state  of  the  heart  is  generally  accompanied  with  an 
ossification  or  thickening  of  some  of  the  valves,  and  has 
depended  upon  the  diseased  condition  of  the  valves  as  its 
cause.     It  may  however  occur  without  any  of  the  valves 
being  diseased,  or  any  apparent  disease  in  the  structure 
of  the  heart.     Any  cause  which  would  produce  a  strong 
and  permanent  impediment  to  the  circulation  of  the  blood 
through  the  lungs,   or  to   the   current   of  blood  in  the 
aorta  near  the  heart,  would  in  time  produce  an  enlarge- 
ment of  it.     The  cavities  of  the  heart  in  such  cases  are 
generally  filled   with  blood,    which   is  partly  fluid   and 
partly  concreted  into  a  loose  coagulum. 

Hydatids  adhering  to  the  Heart. 

Hydatids*  have  occasionally  been  found  adhering  to  the 
heart ;  but  I  have  not  met  myself  with  any  instances  of 
this  sort.  They  do  not  appear  to  be  of  the  same  kind  in 
every  part  of  the  body ;  but  their  nature  will  be  explained 
particularly,  when  I  come  to  describe  the  diseased  ap- 
pearances of  the  liver  and  kidneys. 

*  See  Morgagni,  Epist.  XXV.  Art.  15. 


A  portion  of  the  Heart  bony^  or  earthy. 

A  portion  of  the  heart  has  been  observed  to  be  con- 
verted into  bone.*  Earthy  matter  has  also  been  found  de- 
posited in  the  muscular  substance  of  the  heart. f  Neither 
of  these  appearances  has  come  under  my  own  observation, 
end  they  are  to  be  looked  upon  as  very  uncommon. 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  of  the  heart 
are  very  much  the  same  with  those  which  belong  to  in- 
flammation of  the  pericardium,  viz.  symptomatic  fever; 
more  or  less  pain  in  the  situation  of  the  heart;  palpitations; 
an  irregular  pulse;  cough;  difficulty  of  breathing;  and 
often  syncope.  It  would  seem  probable  that  the  last 
symptom  is  principally  connected  with  inflammation  of 
the  substance  of  the  heart,  and  perhaps  it  may  not  be  found 
in  a  pure  inflammation  of  the  pericardium.  The  two 
diseases,  however,  are  very  commonly  blended  together. 


The  symptoms  which  attend  aneurysm  of  the  heart, 
are  nearly  similar  to  those  which  belong  to  aneurysm  of 
the  arch  of  the  aorta. 

*  See  Morgagni,  Epist.  XXVII.  Art.  16.    See  also  Medical  Communica- 
tions, Vol.  I.  p.  228. 
f  See  Bonetus,  Tom.  1.  p,  820,  and  p.  825, 


The  place  of  the  pulsation  will  be  lower  than  in  aneurysm 
of  the  arch  of  the  aorta,  and  the  space  occupied  by  the 
pulsation  will  in  general  be  larger  than  in  aneurysm  of 
this  part  of  the  aorta. 


The  chief  symptom  which  attends  aneurysm  of  the 
arch  of  the  aorta,  in  an  early  stage  of  the  disease,  is  a 
strong  pulsation  in  the  chest.  The  pulsation  is  commonly 
at  the  same  time  visible  to  the  eye,  when  the  chest  is 
exposed  to  view.  We  are  not  to  conclude,  however, 
from  this  symptom  only,  that  there  is  certainly  an  aneurysmu 
I  have  felt  the  same  kind  of  pulsation  in  other  cases;  as 
for  instance,  where  the  pericardium  was  found  strongly 
to  adhere  to  the  heart;  where  there  was  a  slight  inflam- 
mation upon  the  surface  of  the  heart,  with  a  little  more 
water  than  usual  in  the  pericardium ;  and  where  a  morbid 
enlargement  had  taken  place  in  the  heart  without  any 
aneurysmal  swelling.  But  when  an  aneurysm  of  the  arch 
of  the  aorta  has  advanced  to  a  large  size,  a  tumour  begins 
to  be  formed  externally,  accompanied  with  a  strong  pul- 
sation. This  I  believe  belongs  only  to  aneurysm,  and 
becomes  the  most  decided  characteristic  of  this  disease. 
The  pulse  at  the  wrist  in  aneurysm  of  the  arch  of  the 
aorta  is  sometimes  irregular;  but  often  no  irregularity 
can  be  felt  in  it.  There  is  generally  more  or  less  of  pain 
in  the  aneurysmal  tumour,  or  in  some  other  part  of  the 
chest.  Difficulty  of  breathing  upon  taking  exercise  also 
commonly  attends  this  disease,  which  is  increased  in  pro- 
portion as  the  disease  advances,  sometimes  to  a  most 
distressing  degree.  It  is  not  very  unusual  for  patients  to 


29 

be  destroyed  by  the  pressure  of  an  aneurysm  of  the  aorta 
upon  the  lungs  and  the  other  important  organs  contained 
in  the  chest,  without  the  aneurysm  bursting  either  ex- 
ternally or  internally. 


Ossification  of  the  coronary  arteries  would  seem  to 
produce,  or  to  be  intimately  connected  with  the  symptoms 
which  constitute  angina  pectoris.  These  consist  of  a 
pain  which  shoots  from  the  middle  of  the  sternum  across 
the  left  breast,  and  passes  down  the  left  arm,  to  near  the 
elbow,  sometimes  even  to  the  wrist  of  the  left  hand.  In 
a  few  cases  the  pain  has  been  known  to  shoot  across  the 
right  breast  as  well  as  the  left,  and  to  pass  down  the  right 
arm,  either  to  near  the  elbow  or  the  wrist.  It  is  excited 
by  walking,  more  especially  up  an  ascent,  and  by  any 
considerable  emotion  of  the  mind.* 


The  symptoms  which  are  produced  by  a  diseased 
alteration  in  the  structure  of  the  valves  of  the  heart,  are 
not  so  distinct  as  to  be  clearly  discriminated  in  practice. 
They  consist  of  difficulty  of  breathing;  of  frequent 
palpitations;  of  a  weak  and  often  an  irregular  pulse;  and  in 
some  cases  there  has  been  observed  a  disposition  to  fainting. 
No  observations  have  yet  been  made  by  which  practi- 
tioners can  ascertain  with  any  precision  what  set  of  valves 
is  diseased. 

*  See  an  excellent  treatise  upon  this  subject  by  Dr.  Party, 


oO 

The  Symptoms  which  have  been  noticed  as  attending 
gradual  effusion  of  blood  into  the  pericardium  are  a  great 
degree  of  faintness;  difficulty  of  breathing;  much  anxiety 
and  oppression;  a  dull  pain,  and  a  sense  of  weight  behind 
the  sternum.  To  these  a  -cold  clammy  sweat  has  been 
observed  to  succeed,  and  to  spread  over  the  body. 


When  the  heart  is  much  enlarged,  the  disease  is  at- 
tended with  palpitations.  These  may  not  only  be  felt 
by  the  hand,  when  applied  to  the  left  side,  but  may  often 
be  perceived  by  the  eye,  even  when  the  chest  is  covered 
with  the  ordinary  clothing.  In  one  or  two  instances,  I 
have  known  the  pulse  at  the  wrist  to  beat  with  an  unusual 
degree  of  vigour,  but  much  more  commonly  the  pulse  is 
feeble  and  irregular.  The  muscular  parietes  of  the  heart 
being  generally  thin  in  proportion  to  the  enlarged  size  of 
its  cavities,  the  heart  has  little  power  to  propel  £n  in- 
creased quantity  of  blood  into  the  more  distant  branches 
of  the  arterial  system.  At  times  there  is  much  difficulty 
of  breathing;  and  there  is  a  purplish  hue  of  the  cheeks  and 
lips.  The  colour  is  more  deep  in  its  tinge  at  one  time 
than  another,  according  as  the  blood  has  been  transmitted 
with  more  or  less  difficulty  through  the  lungs.  The 
causes  which  produce  a  morbid  growth  of  the  heart  are 
probably  not  all  of  them  yet  ascertained.  The  chief 
cause  is  an  ossification  or  thickening  of  some  of  its  valves, 
On  some  occasions  the  heart  will  become  enlarged  from 
rheumatism  attacking  it.* 

*  Dr.  Pitcairn  has  observed  this  in  several  cases,  and  is  to  be  considered  ac 
the  first  person  who  made  this  important  observation,    Its  accuracy  has  beer 


31 

The  symptoms  produced  by  the  formation  of  hydatids3 
in  the  cavity  of  the  pericardium,  are  not  distinctly  known; 
but  they  cannot  be  supposed  to  diier  much  from  those  of 
water  in  the  pericardium.  In  a  case  related  by  Morgagni, 
the  patient  was  subject  to  fainting. 

.  When  a  part  of  the  heart  is  converted  into  an  earthy 
matter  or  bone,  no  morbid  symptoms  whatever  have,  in 
some  cases,  been  observed ;  and  in  others  there  has  been 
palpitation  of  the  heart,  with  difficulty  of  breathing.* 

confirmed  within  these  few  years  by  different  individuals,  some  of  whom  are 
of  high  professional  character,  so  that  it  may  now  be  regarded  as  an  established 
pathological  fact. 

*  Those  who  wish  to  consider  this  important  subject  more  minutely,  will 
consult  with  great  advantage  the  excellent  work  of  Corvisart  upon  Diseases 
of  the  Heart, 


CHAPTER  III. 

DISEASED   APPEARANCES  IN   THE   CAVITY   OE   THE 
THORAX. 

Inflammation. 

THE  pleura,  or  the  membrane  which  lines  the  cavity 
of  the  thorax,  is  very  subject  to  inflammation.  This 
may  take  place  at  any  period  of  life,  but  it  is  more  frequent 
at  the  age  when  the  body  is  just  arrived  at  the  adult 
state,  and  all  its  actions  are  carried  on  with  vigour,  than 
either  in  childhood  or  in  advanced  age.  The  pleura  ap- 
pears to  be  more  liable  to  inflammation  than  any  mem- 
brane lining  those  cavities  which  have  no  external  opening, 
as  the  peritonasum,  the  tunica  vaginalis  testis,  and  some 
others.  This  may  arise  from  the  following  causes.  The 
branches  of  the  intercostal  vessels,  which  are  very  nume- 
rous, piercing  through  the  substance  of  the  intercostal 
muscles,  communicate  a  good  deal  by  anastomosis,  with 
the  external  vessels  on  the  sides  of  the  chest.  Hence 
whatever  may  act  upon  these  external  vessels  so  as  to 
excite  contraction  in  them,  may  be  supposed  capable  of 
producing  an  accumulation  of  blood,  as  well  as  an  in- 
creased action  in  the  inner  branches  of  the  intercostals, 
many  of  which  are  distributed  upon  the  pleura.  Many 
of  the  inhabitants  of  this  country,  from  their  mode  of 
dress,  have  their  chests  much  exposed  to  the  influence 
of  a  cold  and  very  uncertain  climate,  and  hence  the  blood 
is  frequently  thrown  inwards  into  the  small  vessels  ramifying 


33 

Upon  the  pleura.  For  these  reasons  probably  the  pleura 
is  more  liable  to  inflammation  than  other  membranes  in- 
vesting cavities  which  have  no  external  opening-.  This 
is  so  much  the  case^  that  one  can  hardly  examine  the 
chest  of  any  person  who  has  arrived  at  the  adult  state, 
without  perceiving  more  or  less  the  traces  of  a  present  or 
former  inflammation. 

When  the  pleura  is  inflamed,  it  becomes  thicker  than 
it  is  naturally,  and  in  some  degree  pulpy.  There  are  also 
interspersed  through  it  a  great  number  of  very  small 
vessels  containing  florid  blood,  and  a  layer  of  coagulable 
lymph  is  at  the  same  time  formed  upon  its  surface.  This 
layer  is  sometimes  very  thin,  and  at  other  times  of  con- 
siderable thickness.  It  is  either  smooth  upon  its  surface, 
or  it  throws  out  many  small  flocculi,  which  exhibit  the 
appearance  of  a  rich  lace- work.  A  serous  fluid  is  also 
poured  into  the  cavity  of  the  thorax,  in  which  are  floating 
many  small  broken  laminse  of  the  coagulable  lymph;  and 
there  is  occasionally  some  mixture  of  pus. 

The  coagulable  lymph  covering  the  pleura  which  forms 
the  external  membrane  of  the  lungs,  frequently  adheres 
to  that  which  covers  the  pleura  that  is  reflected  on  the 
inside  of  the  parietes  of  the  chest,  either  in  small  portions, 
or  by  extended  surfaces*  Upon  such  occasions  I  have 
sometimes  been  able  to  trace  the  gradual  change  of  the 
adhesion,  from  the  state  of  coagulable  lymph  to  that  of 
cellular  membrane.  This  coagulable  lymph  may  be 
shewn  to  be  vascular  by  injection,  as  we  have  already 
mentioned  in  the  inflammation  of  the  pericardium.  When 
the  pleura  is  inflamed  which  covers  the  lungs,  the  substance 
of  the  latter  is  frequently  inflamed  to  some  depth. 


Adhesions  in  the  Cavity  of  the  Thorax. 

Adhesions  are  often  found  between  that  portion  of  the 
pleura  which  covers  the  lungs,  and  that  other  portion  of 
it  which  lines  the  ribs,  the  intercostal  spaces,  and  the 
convex  surface  of  the  diaphragm,  while  there  is  no  sign 
whatever  of  present  inflammation.  These  adhesions  are 
often  partial,  and  then  they  are  most  commonly  to  be 
found  at  the  upper  and  posterior  part  of  the  chest ;  but 
they  are  sometimes  extended  over  the  whole  cavity.  They 
either  connect  the  parts  together  closely,  in  which  case 
they  often  consist  of  a  firm  thick  membrane;  or  they 
connect  them  loosely,  and  then  they  consist  of  a  soft 
spongy  membrane,  which  exactly  resembles  the  common 
cellular  membrane  of  the  body.  Such  adhesions  are  the 
consequence  of  inflammation,  and  are  perhaps  the  most 
common  morbid  appearance  to  be  found  in  dead  bodies. 

Empyema. 

Pus  is  not  unfrequently  accumulated  in  the  cavity  of 
the  chest,  forming  the  disease  called  empyema.  This 
may  either  arise  from  the  blood  vessels  of  the  pleura 
being  in  such  a  state  of  inflammation  as  to  form  pus,  or 
from  the  bursting  of  some  abscess  in  the  lungs,  so  as  to 
evacuate  its  pus  into  the  cavity  of  the  thorax.  When 
pus  is  formed  by  an  inflamed  state  of  the  pleura,  there  is 
no  occasion  for  ulceration  to  take  place.  The  pleura  is 
found  entire,  but  is  covered  with  a  layer  of  the  coagulable 
lymph.  This  fact  has  been  long  ago  ascertained  by  the 
late  Dr.  Hunter.  The  formation  of  the  pus  depends  on 
a  certain  mode  of  action  in  the  vessels  of  the  pleura,  or 
more  probably  of  the  layer  of  the  coagulable  lymph  which 


35 

covers  it.  The  pus  may  either  occupy  the  whole  of  one 
of  the  cavities  of  the  chest,  or  may  be  confined  to  a  part 
of  it  by  adhesions  taking  place  between  the  lungs  and 
that  portion  of  the  pleura  which  invests  the  ribs  and  the 
intercostal  spaces.  When  pus  is  evacuated  into  the  cavity 
of  the  chest  by  the  bursting  of  an  abscess  in  the  lungs, 
it  is  almost  always  confined  within  certain  limits  by  ad- 
hesions, in  cases  of  empyema,  for  the  most  part,  there 
is  not  any  particular  appearance  of  the  chest  observable 
on  the  outside :  there  is  sometimes  however  a  fullness  to 
be  perceived  externally  on  the  side  where  the  matter  is 
accumulated,  and  even  occasionally  an  evident  swelling 
between  two  of  the  ribs,  as  of  matter  pointing.  Ulceration 
has  also  been  known  to  take  place  in  one  of  more  of  the 
intercostal  spaces,  so  that  the  matter  has  been  evacuated 
externally.  There  is  an  example  in  Dr.  Hunter's  col- 
lection, where  the  matter  had  been  evacuated  from  the 
chest  by  several  openings  in  the  intercostal  spaces. 

Hydrothorax. 

A  watery  fluid  is  not  uncommonly  found  in  one  or  both 
cavities  of  the  chest,  forming  the  disease  called  hydro- 
thorax.  It  is  often  attended  with  the  accumulation  of 
water  in  other  parts  of  the  body,  especially  in  the  peri- 
cardium, and  in  the  cellular  membrane  of  the  lower  ex- 
tremities. The  fluid  in  hydrothorax  is  commonly  of  a 
brown  or  yellowish  colour,  but  occasionally  has  a  reddish 
colour,  arising  from  the  mixture  of  the  red  globules  of 
blood.  It  resembles  in  its  properties  the  serum.  It  is 
found  to  vary  a  good  deal  in  quantity  in  different  cases, 
sometimes  amounting  only  to  a  few  ounces,  and  at  other 
times  to  several  quarts.  When  it  is  accumulated  in  very 


36 

large  quantity  in  either  side  of  the  chest,  that  side  appears 
to  be  fuller  to  the  eye  externally;  and  when  the  cavity  is 
laid  open  after  death,  the  lungs  on  that  side  are  found 
more  or  less  compressed.  I  have  seen  one  of  the  lungs 
so  compressed  from  this  cause  as  not  to  be  larger  than 
the  closed  fist. 

Water  is  likewise  found  in  the  cavity  of  the  chest 
where  there  are  considerable  adhesions.  This  shews  that 
a  good  deal  of  inflammation  had  formerly  taken  place, 
which  had  probably,  by  .throwing  out  a  considerable 
quantity  of  serum,  laid  the  foundation  of  the  hydrothorax.* 

Steatomatous  7  umours  and  Hydatids. 

Steatomatous  tumours  and  hydatids  have  sometimes 
been  found  in  the  cavity  of  the  pleura,  but  both  these 
morbid  appearances  are  very  rare.f 

The  Pleura  almost  dry. 

In  opening  into  the  cavity  of  the  chest,  there  is  com- 
monly found  a  good  deal  of  moisture  upon  the  surface  of 
the  pleura.  This  is  intended  to  lubricate  the  surface  of 
the  cavity  of  the  chest,  for  the  more  easy  motion  of  the 
lungs  within  it.  Sometimes,  however,  I  have  seen  the 
moisture  in  very  small  quantity,  so  that  the  pleura  might 
almost  be  said  to  be  dry.  This  was  occasioned  either 
by  a  deficiency  in  the  action  of  the  exhalent  arteries  of  the 
pleura,  or  by  an  increased  action  of  its  absorbents. 

Ossification  of  the  pleura. 
It  sometimes  happens,  although  I  believe  rarely,  that 

*This  circumstance  is  illustrated  in  several  instances  by  Mr.  Cruikshanlr, 
in  his  Treatise  upon  the  Absorbent  System.     See  2d  edition,  p.  116. 
f  See  Portal's  Anatomic  Medicale,  Tom,  v.  p.  26  and  27. 


37 

a  portion  of  the  pleura  is  converted  into  bone.  This  con- 
sists of  a  thin  plate,  and  sometimes  extends  over  a  conside- 
rable surface  of  the  pleura.  In  all  the  cases  which  I 
have  seen,  the  bony  matter  seemed  to  me  to  be  exactly 
like  common  bone.  I  have  never  seen  it  form  a  thick 
irregular  knob,  but  always  a  thin  plate.  The  cause  which 
first  excites  this  diseased  process  it  is  very  difficult  to 
determine;  but  there  can  be  no  doubt  that  the  bone  is 
formed  by  the  small  vessels  of  the  pleura,  which  secrete 
bony  matter  from  the  blood.  This  process  is  not  peculiar 
to  the  pleura,  but  takes  place  in  almost  every  part  of  the 
body;  I  believe,  however,  that  it  is  more  common  in  the 
pleura,  than  in  any  other  similar  membrane.  In  the  cases 
which  I  have  observed,  this  process  seemed  not  to  have 
attended  with  much  inconvenience.  There  was  no  in- 
flammation found  in  the  pleura  surrounding  the  bone,  nor 
in  the  substance  of  the  lungs  under  it.  It  is  reasonable 
to  think,  however,  if  the  bone  were  to  grow  irregularly, 
so  as  to  form  sharp  processes,  that  it  might  excite  in- 
flammation, and  lay  the  foundation  of  a  fatal  disease.'* 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  of  the  pleura 
are  very  well  ascertained.  There  is  more  or  less  of 
symptomatic  fever;  an  acute  pain  in  some  part  of  the 

*  A  case  is  mentioned  by  Dr.  Soemmering,  where  a  part  of  the  lungs  was 
found  inflamed  and  suppurated  under  an  ossification  of  the  pleura.  See 
Soemmer.  Germ.  Translat.  of  the  Morbid  Anatomy,  p.  43. 


38 

chest,  more  commonly  in  the  side,  which  is  increased 
upon  inspiration;  a  great  difficulty  in  lying  upon  the 
diseased  side;  difficult  respiration;  a  cough,  which  at  first 
is  dry,  but  is  afterwards  accompanied  with  a  secretion 
and  expectoration  of  mucus  from  the  inner  membrane  of 
the  trachea  and  its  branches. 

There  would  often  seem  to  be  slight  degrees  of  in- 
flammation in  the  pleura,  where  the  symptoms  above  stated 
do  not  exist  at  all,  or  are  so  obscurely  marked  as  to  be 
altogether  overlooked.  In  examining  the  chest  of  adults 
after  death,  it  rarely  happens  that  adhesions  are  not  dis- 
covered in  some  part  of  it,  uniting  the  surface  of  the  lungs 
to  that  portion  of  the  pleura  which  lines  the  parietes  of 
the  chest.  The  marked  symptoms  of  pleurisy,  however, 
are  by  no  means  so  frequent.  It  seems,  therefore,  probable, 
that  slight  inflammations  may  attack  the  pleura,  sufficient 
to  throw  out  coagulable  lymph,  which  is  afterwards 
changed  into  adhesions,  and  yet  that  persons  thus  affected 
shall  not  be  sensible  of  any  disease  in  the  chest.  If  this 
supposition  be  not  granted,  then  coagulable  lymph  may 
be  poured  out  upon  the  surface  of  the  pleura,  and  ad- 
hesions be  formed  without  inflammation:  but  this  con- 
jecture is  not  so  probable  as  the  other. 


Where  adhesions  in  the  chest  are  long,  so  as  not  to 
impede  the  free  motion  of  the  lungs,  respiration  is  not 
sensibly  affected  by  them.  But  where  the  adhesions  are 
short,  tying  as  it  were  the  lungs  closely  to  the  parietes 
of  the  chest,  and  more  especially  if  they  be  extended  over 
every  part  of  the  cavity,  then  respiration  is  difficult,  and 


59 


accompanied  with  a  cough,  but  there  are  no  symptoms 
of  fever. 


Empyema  may  be  distinguished  with  a  good  deal  of 
certainty,  after  inflammation  of  the  pleura  or  of  the  lungs, 
by  rigors  having  taken  place,  by  a  remission  of  the  pain, 
by  the  cough  and  difficulty  of  breathing  continuing,  and 
by  the  person  being  able  to  lie  more  easily  upon  the 
diseased  side  than  the  other.  There  is  sometimes  a  very 
evident  enlargement  of  the  side  where  the  matter  is  ac- 
cumulated, and  always  a  want  of  that  hollow  sound  on 
striking  with  the  fingers  the  side  where  the  empyema  is, 
which  takes  place  upon  striking  the  chest,  where  the  lungs 
are  sound. 


When  water  is  accumulated  in  the  chest,  it  can  gene- 
rally be  sufficiently  distinguished  in  practice  by  the 
following  symptoms. 

There  is  great  difficulty  of  breathing,  and  commonly 
the  patient  cannot  rest  in  bed  unless  the  head  and  upper 
part  of  the  trunk  be  more  or  less  elevated  from  the 
horizontal  posture.  The  sleep  is  often  suddenly  in- 
terrupted by  alarms  and  disagreeable  dreams;  the  urine 
is  in  very  small  quantity,  and  there  is  commonly  .anasarca 
of  the  legs.  The  pulse  is  generally,  but  not  always, 
irregular.  There  is  a  paleness  in  the  countenance,  with 
a  purple  hue  of  the  lips  and  of  the  cheeks,  if  the  latter 
should  happen  to  have  any  tinge  remaining.  This  effect 


40 

is  produced  by  the  lungs  being  incapable  of  sufficiently 
expanding  themselves  to  receive  the  quantity  of  air  which 
is  necessary  for  giving  the  usual  florid  colour  to  the  blood 
in  the  branches  of  the  pulmonary  artery, 


When  ossification  of  the  pleura  is  of  small  extent, 
respiration  cannot  be  affected  by  it;  but  when  it  is  large, 
it  must  produce  difficulty  of  breathing,  either  by  preventing 
the  full  expansion  of  the  lungs,  or  the  free  motion  of  the 
ribs,  according  to  its  situation :  Some  instances  are  known 
of  respiration  being  injured  from  this  cause. 

Where  the  ossification  has  produced  inflammation  of 
the  pleura  and  lungs,  symptoms  of  inflammation  will  take 
place  as  above  described,  but  probably  in  some  cases 
there  may  be  peculiar  symptoms,  depending  chiefly  on 
the  different  irritability  of  different  constitutions.  In  one 
case  there  were  paroxysms  of  convulsive  difficulty  of 
breathing,  palpitation  of  the  heart,  a  quick  irregular  pulse, 
and  a  distressing  sense  of  instant  suffocation.* 

*  See  Mr.  Weldon's  Observations  on  Surgery,  p.  75  and  76. 


41 


CHAPTER  IV. 

DISEASED   APPEARANCES   OF   THE  LUNGS. 

I 

Inflammation. 

INFLAMMATION  of  the  substance  of  the  lungs,  I  be- 
lieve, seldom  takes  place  without  some  similar  affection 
of  the  pleura;  at  least  in  the  instances  which  I  have  seen, 
this  has  been  most  frequently  the  case.  When  a  portion 
of  the  lungs  is  inflamed,  its  spongy  structure  appears 
much  redder  than  usual;  the  colour  being  chiefly  florid, 
but  partly  of  a  darker  hue.  This  arises  from  a  great- 
number  of  the  small  vessels  distributed  upon  the  cells  of 
the  lungs,  being  so  enlarged  as  to  admit  the  red  globules 
of  the  blood.  There  is  also  an  extravasation  of  the 
coagulable  lymph  into  the  substance  of  the  lungs,  and 
sometimes  of  blood.  The  extravasated  blood  has  been 
said  upon  some  occasions  to  be  in  very  large  quantity; 
but  this  has  never  fallen  under  my  own  observation. 

That  portion  of  the  lungs  which  is  inflamed  becomes 
considerably  heavier  than  in  the  natural  state,  from  the 
accumulation  of  blood  in  its  vessels,  and  the  extravasation 
of  the  coagulable  lymph;  it  therefore  commonly  sinks  in 
water.  It  feels  like  a  solid  substance  when  pressed  by 
the  fingers,  and  there  is  no  crackling  of ,  air  as  in  the 
healthy  structure.  This  however  will  be  more  or  less 
marked,  according  to  the  degree  of  the  inflammation. 

The  pleura  covering  the  inflamed  portion  of  the  lungs 
fa  also  commonly  affected  with  inflammation;  it  is  crowded 
F 


42 

with  fine  red  vessels,  and  has  generally  lying  upon  it  a 
layer  of  coagulable  lymph. 

This  inflamed  state  of  the  lungs  is  to  be  distinguished 
from  blood  accumulated  in  some  part  of  them  after  death 
in  consequence  of  gravitation.  From  the  body  lying  in 
the  horizontal  posture  after  death,  blood  is  generally  ac- 
cumulated at  the  posterior  part  of  the  lungs,  giving  them 
there  a  deeper  colour,  and  rendering  them  heavier.  In  this 
case  there  will  be  found  no  crowd  of  fine  vessels  filled 
with  blood,  nor  will  the  lungs  be  found  solid,  but  spongy 
in  their  texture,  and  there  will  be  no  other  mark  of  in- 
flammation of  the  pleura. 

Where  blood  too  is  accumulated  in  any  part  of  a  lung 
after  death,  from  gravitation,  it  is  always  of  a  dark  colour; 
but  where  blood  is  accumulated  from  inflammation,  the 
inflamed  part  will  appear,  in  a  great  measure,  florid. 

Abscesses. 

It  is  very  common  to  find  abscesses  in  the  lungs. 
These  sometimes  consist  of  small  cavities  containing  pus, 
and  at  other  times  the  cavities  are  very  large,  so  that  the 
greater  part  of  the  substance  of  the  lungs  has  been  de- 
stroyed. These  cavities  sometimes  communicate  only 
with  branches  of  the  trachea,  which  are  destroyed  in  the 
progress  of  the  ulceration;  at  other  times  they  open  into 
the  cavity  of  the  chest,  emptying  their  contents  there, 
and  forming  the  disease  which  is  called  empyema.  When 
abscesses  are  deeply  seated  in  the  substance  of  the  lungsy 
the  pleura  is  commonly  not  affected;  but  when  abscesses 
are  formed  near  the  surface,  it  is  almost  constantly  in- 
flamed. The  lungs  round  the  boundaries  of  an  abscessr 
when  it  has  arisen  from  common  inflammation,  are  more 


43 

in  their  texture,  in  consequence  of  coagulable  lymph 
being  poured  out  during  the  progress  of  the  inflammation. 
When  the  abscesses  are  scrofulous,  the  texture  of  the 
lungs  in  the  neighbourhood  is  sometimes  not  firmer  than 
usual,  but  presents  the  common  natural  appearance.  This 
I  believe  to  be  principally  the  case  when  the  abscesses 
are  small,  and  placed  at  a  considerable  distance  from  each 
other.  -When  a  portion  of  the  lungs  is  crowded  with 
tubercles,  and  some  of  these  are  converted  into  abscesses, 
the  intermediate  substance  of  the  lungs  is  often  of  a  very 
solid  texture.  When  blood  vessels  are  traced  into  an 
abscess  of  the  lungs,  I  have  found  them,  upon  examination, 
very  much  contracted,  just  before  they  reach  the  abscess, 
so  that  the  opening  of  their  extremities  has  been  closed 
up  entirely.  On  such  occasions  it  will  require  a  probe 
to  be  pushed  with  a  good  deal  of  foree,  in  order  to  open 
again  their  extremities.  In  these  contracted  vessels  the 
blood  is  coagulated,  as  it  is  under  similar  circumstances 
in  other  parts  of  the  body.*  This  change  in  the  blood 
vessels  is,  no  doubt,  with  a  view  to  prevent  large 
haemorrhages  from  taking  place,  which  would  be  almost 
immediately  fatal. 

Tubercles. 

There  is  no  morbid  appearance  so  common  in  the  lungs 
as  that  of  tubercles.  These  consist  of  rounded  firm 
white  bodies,  interspersed  through  their  substance.  They 
are,  probably,  formed  in  the  cellular  structure,  which 
connects  the  air  cells  of  the  lungs  together,  and  are  not  a 
morbid  affection  of  glands,  as  has  been  frequently  imagined. 
There  is  no  glandular  structure  in  the  cellular  connecting 

See  Dr.  Stark's  Works,  p.  28. 


44 

membrane  of  the  lungs;  and  on  the  inside  of  the  branches 
of  the  trachea,  where  there  are  follicles,  tubercles  have 
never  been  seen.  They  are  at  first  very  small,  being  not 
larger  than  the  heads  of  very  small  pins,  and  in  this  case 
are  frequently  accumulated  in  small  clusters.  The  smaller 
tubercles  of  a  cluster  probably  grow  together,  and  form 
one  larger  tubercle.  The  most  ordinary  size  of  tubercles 
is  about  that  of  a  garden  pea,  but  they  are  subject  in  this 
respect  to  much  variety.  They  adhere  closely  to  the 
substance  of  the  lungs,  have  no  peculiar  covering  or 
capsule,  and  have  little  or  no  vascularity.  When  cut  into, 
they  are  found  to  consist  of  a  white  smooth  substance, 
possessing  a  firm  texture,  and  they  often  contain  in  part 
a  thick  curdly  pus.  When  a  tubercle  is  almost  entirely 
changed  into  pus,  it  appears  like  a  white  capsule  in  which 
the  pus  is  lodged.  When  several  tubercles  of  considerable 
size  are  grown  together  so  as  to  form  a  large  tuberculated 
mass,  pus  is  very  generally  found  upon  cutting  into  it. 
The  pus  is  frequently  thick  and  curdly;  but  when  in 
xonsiderable  quantity,  it  is  thinner,  and  resembles  very 
much  the  pus  from  a  common  sore.  In  cutting  into  the 
substance  of  the  lungs,  a  number  of  abscesses  is  some- 
times found,  from  tubercles  of  a  considerable  size  having 
advanced  to  a  state  of  suppuration.  In  the  interstices 
between  these  tubercles,  the  lungs  are  frequently  of  a  solid 
texture,  from  the  cells  being  in  a  great  measure  obliterated. 
The  texture  of  the  lungs  on  many  occasions,  however, 
round  the  boundaries  of  an  abscess,  is  perfectly  natural. 

I  have  sometimes  seen  a  number  of  small  abscesses 
interspersed  through  the  lungs,  each  of  which  was  not 
larger  than  a  pea.  The  pus  in  these  is  rather  thicker  than 
ivhat  arises  from  common  inflammation,  and  resembles 


45 

scrofulous  pus.  It  is  probable  that  these  abscesses  have 
been  produced  by  a  number  of  small  scattered  tubercles 
taking  on  the  process  of  suppuration.  The  lungs  immedi- 
ately surrounding  these  abscesses  are  often  of  a  perfectly 
healthy  structure,  none  of  the  cells  being  closed  up  by 
adhesions. 

When  tubercles  are  converted  into  abscesses,  phthisis 
pulmonalis  is  produced,  one  of  the  most  destructive 
diseases  in  this  island.  Tubercles  are  sometimes  found 
in  the  lungs  of  children  at  a  very  early  age,  viz.  two  or 
three  years  old;  but  they  most  frequently  occur  a  short 
time  before  the  completion  of  the  growth.  They  are 
apt  likewise  to  be  formed  at  rather  an  advanced  age. 

In  cutting  into  the  lungs,  a  considerable  portion  of 
their  structure  sometimes  appears  to  be  changed  into  a 
whitish  soft  matter,  somewhat  intermediate  between  a 
solid  and  a  fluid,  like  a  scrofulous  gland  just  beginning 
to  suppurate.  This  appearance  I  believe  is  produced  by 
scrofulous  matter  being  deposited  in  the  cellular  substance 
of  a  certain  portion  of  the  lungs,  and  advancing  towards 
suppuration.  It  seems  to  be  the  same  matter  with  that 
of  the  tubercle,  but  only  diffused  uniformly  over  a  con- 
siderable portion  of  the  lungs,  while  the  tubercle  is  cir- 
cumscribed. 

Soft  pulpy  Tubercles. 

I  have  seen  another  sort  of  tubercle  in  the  lungs,  which 
I  believe  to  be  very  rare.  It  consists  of  a  soft  tumour, 
formed  of  a  light  brown,  smooth  substance.  This  is  not 
contained  in  any  proper  capsule,  but  adheres  immediately 
to  the  common  structure  of  the  lungs.  In  cutting 
through  several  of  these  tumours  I  did  not  find  any  of 


46 

them  in  a  state  of  suppuration.  They  were  commonly 
as  large  as  a  gooseberry,  and  were  chiefly  placed  upon 
the  surface  of  the  lungs;  some,  however,  were  scattered 
through  their  substance,  of  a  smaller  size.  These  are 
very  different  in  their  appearance  from  the  common 
tubercle  last  described. 

Water  accumulated  in  the  Substance  of  the  Lungs. 

The  structure  of  the  lungs  may  be  said  to  consist  of 
air  cells,  and  the  common  cellular  membrane  of  the  body. 
In  this  cellular  membrane  there  is  always  some  moisture, 
which  is  necessary  for  the  easy  motion  of  one  part  of  the 
lungs  upon  another  in  their  contraction  and  dilatation. 
There  is  a  considerable  difference  in  the  quantity  of  this 
moisture  in  different  persons,  as  may  be  seen  by  cutting 
into  the  substance  of  the  lungs;  for  under  such  circum- 
stances there  will  always  ooze  out  from  the  cut  surface 
more  or  less  of  an  aqueous  fluid  mixed  with  globules  of 
air.  Sometimes,  however,,  the  quantity  is  so  large  that 
it  amounts  to  a  disease,  forming  what  may  be  called 
anasarca  of  the  lungs.  It  has  not  occurred  to  me  to  see 
any  well  marked  example  of  this  disease,  but  it  has  been 
observed  by  others.*  It  is  hardly  necessary  to  mention, 
that  in  proportion  to  the  accumulation  of  the  water,  the 
air  cells  must  be  necessarily  compressed,  so  that  a  sufficient 
quantity  of  air  cannot  be  admitted  into  the  lungs  for  pro- 
ducing the  due  degree  of  influence  upon  the  blood. 

Lungs  distended  with  Air. 

In  opening  into  the  chest,  it  is  not  unusual  to  find  that 
the  lungs  do  not  collapse,  but  that  they  fill  up  the  cavity 

*  See  Dr.  Soemmering's  German  translation  of  the  Morbid  Anatomy,  p.  45. 


47 

completely  on  each  side  of  the  heart.  When  examined; 
their  cells  appear  full  of  air,  so  that  a  prodigious  number 
of  small  white  vesicles  are  seen  upon  the  surface  of  the 
lungs  immediately  under  the  pleura.  The  branches  of 
the  trachea  are  often  at  the  same  time  a  good  deal  filled 
with  the  mucous  fluid.  This  fluid  had  probably  pre- 
sented the  ready  egress  of  the  air,  so  that  it  had  gradually 
distended  the  air  cells  of  the  lungs,  and  had  prevented  the 
lungs  from  collapsing. 

Air  Cells  of  the  Lungs  enlarged. 

The  lungs  are  sometimes,  although  I  believe  very  rarely, 
formed  into  pretty  large  cells,  so  as  to  resemble  somewhat 
the  lungs  of  an  amphibious  animal.  Of  this  I  have  now 
seen  three  instances.  The  enlargement  of  the  cells  can- 
not well  be  supposed  to  arise  from  any  other  cause,  than 
the  air  being  not  allowed  the  common  free  egress  from 
the  lungs,  and  therefore  accumulating  in  them.  It  is  not 
improbable  also,  that  this  accumulation  may  sometimes 
break  down  two  or  three  contiguous  cells  into  one,  and 
thereby  form  a  cell  of  a  very  large  size. 

Air  Vesicles  attached  to  the  Edge  of  the  Lungs. 

Vesicles  containing  air  have  occasionally  been  seen 
attached  to  the  edge  of  the  lungs.  They  do  not  com- 
municate, however,  with  the  structure  of  this  organ,  but 
are  complete  in  themselves.  Upon  the  first  view,  it 
might  be  thought  probable  that  they  were  merely  some 
of  the  air  cells  enlarged;  but  as  they  do  not  communicate 
with  any  of  the  air  cells,  this  opinion  is  not  well  founded. 
It  is  most  likely  that  they  are  a  morbid  structure,  formed 
in  the  same  manner  as  the  air  vescicles  attached  to  the 


48 

intestines  and  mesentery  of  some  quadrupeds,  and  that 
the  very  minute  blood  vessels  which  ramify  upon  the 
vesicles  have  the  power  of  secreting  the  air.* 

Lungs  changed  into  a  substance  like  Liver. 

The  lungs  are  sometimes  converted  into  a  solid  sub- 
stance very  much  resembling  the  liver.  It  has  nearly  the 
same  solidity,  with  the  natural  texture  of  the  liver,  and 
the  same  general  appearance  of  structure.  1  have  only 
seen  an  example  of  this  change  in  a  preparation,  and  I  am 
inclined  to  believe  that  it  had  been  produced  by  a  wide 
extended  inflammation,  in  which  a  large  quantity  of 
coagulable  lymph  had  been  extravased  into  the  substance 
of  the  lungs.  The  extravasation  would  necessarily  render 
the  texture  of  the  lungs  very  solid;  and  the  history  of  the 
symptoms  which  have  been  observed  to  attend  similar 
morbid  changes,  supports  this  opinion.  The  symptoms 
are  those  which  are  produced  by  an  inflammation  of  the 
lungs. 

Lungs  converted  into  Bone. 

Part  of  the  lungs  is  occasionally  converted  in  a  bony 
substance;  but  this  is  a  very  rare  disease.  The  small 
vessels  ramifying  through  the  substance  of  the  lungs  under 
such  circumstances  separate  bony  matter  from  the  blood. 
In  the  only  instance  which  I  have  known  of  this  complaint, 
the  process  would  appear  to  have  been  rapid.  There 
was  great  difficulty  of  breathing  before  the  person  died, 
but  this  difficulty  had  been  only  for  a  very  few  weeks. 
Each  of  the  lungs  was  undergoing  the  same  change  of 
structure,  which  had  made  considerable  progress.  In  the • 

*  See  Hunter's  Animal  Economy,  p.  165. 


49 

particular  case  to  which  I  allude,  there  had  been  a  very 
strong  disposition  to  form  bone  in  the  constitution.  A 
very  large  bony  tumour  had  been  formed  round  one  of 
the  knees  of  this  person;  and  very  soon  after  the  knee  and 
leg  were  removed  by  amputation,  the  difficulty  of  breathing 
began,  which  was  occasioned  by  a  part  of  the  lungs  being 
converted  into  bone.  In  this  case  there  was  a  transference 
of  the  disease  from  an  external  to  an  internal  part,  similar 
to  the  translation  of  gout  or  rheumatism. 

A  solid  Tumour  compressing  the  Lungs* 

I  have  also  seen  a  tumour  as  large  as  an  orange,  attached 
to  the  lungs  on  one  side  by  a  loose  membranous  con- 
nection,  and  in  some  degree  compressing  them;  this  tu- 
mour consisted  of  a  porous  substance,  which  resembled 
neither  the  structure  of  what  is  commonly  understood 
to  be  a  scirrhous  nor  that  of  a  scrofulous  tumour,  but 
had  an  appearance  somewhat  peculiar  to  itself. 

Earthy  Concretions  in  the  Lungs. 

Earthy  concretions  have  occasionally  been  found  in 
the  lungs,  although  it  is  not  a  common  appearance  of 
disease.  These  are  generally  small,  but  sometimes  form 
masses  of  a  considerable  size.*  Even  a  considerable 
portion  of  the  lungs  has  been  known  to  be  changed  into 
an  earthy  substance.  |  These  concretions  consist  of 
phosphate  of  lime,  united  to  a  thick  membranous  sub- 
stance, which  retains  the  form  of  the  concretion.  J 

*  Vid.  Morgagni,  Epist.  XVII.  Art.  19.  Epist.  XV.  Art.  25. 

j-Vid.  Morgagni  Epist.  XXII.  Art  15. 

t  See  Thompson's  System  of  Chemistry,  Vol.  4,  p,  659- 

G 


Hydatids 

Hydatids  are  also  sometimes  formed  in  the  lungs,  ancl 
are  many  of  them  brought  up  by  coughing.  They  are 
of  the  same  sort  with  the  hydatids  formed  in  the  liver? 
the  nature  of  which  we  shall  endeavour  to  explain 
afterwards. 


SYMPTOMS. 

In  inflammation  of  the  substance  of  the  lungs,  the 
symptoms  correspond  a  good  deal  with  those  of  pleurisy. 
Indeed  inflammation  of  the  lungs  is  almost  constantly 
attended  with  inflammation  of  the  pleura,  so  that  it  is 
difficult  to  discriminate  between  them  in  practice.  But 
it  is  of  little  consequence  to  be  able  to  do  this,  as  the 
means  of  cure  are  the  same  in  both  diseases.  When 
the  inflammation  of  the  lungs  is  pure,  the  pleura  being  not 
affected,  the  pain  in  the  chest  has  been  observed  to  be 
more  obtuse  than  in  pleurisy,  and  the  pulse  to  be  less 
hard.  The  respiration  is  very  difficult,  and  the  veins  of 
the  neck  are  sometimes  observed  to  be  distended  with 
blood,  the  face  to  be  tumid,  and  there  is  a  purplish  hue 
of  the  lips  and  cheeks.  These  effects  arise  from  the  venal 
blood  being  transmitted  with  difficulty  through  the  in- 
flamed lungs.  This  is  occasioned  by  an  extravasation  of 
the  coagulable  lymph  into  a  considerable  part  of  their 
substance,  which  both  prevents  the  lungs  from  sufficiently 
expanding  themselves,  and  compresses  many  air  cells. 


51 

so  that  the  proper  quantity  of  air  is  not  admitted  into  the 
lungs  for  producing  the  full  change  of  colour  upon  the 
blood. 

When  inflammation  of  the  lungs  terminates  in  suppura- 
tion, it  may  be  known  by  rigors,  by  a  dimunution  of  the 
pain  in  the  chest,  by  an  expectoration  of  pus,  and  some- 
times, when  an  abscess  is  large,  by  bringing  up  at  once 
a  great  quantity  of  pus,  which  is  generally  a  little  tinged 
with  blood. 


When  tubercles  are  forming  in  the  lungs,  but  have  not 
advanced  to  suppuration,  they  are  attended  with  a  slight 
cough,  with  occasional  difficulty  of  breathing,  with  the 
feeling  of  slight  pains  in  some  part  of  the  chest,  and  with 
a  pulse  somewhat  accelerated.  These  are  symptoms 
which  commonly  usher  in  phthisis  pulmonalis,  and  are 
frequently  overlooked,  both  by  the  patients  themselves 
and  their  friends.  When  the  tubercles  have  begun  to 
suppurate,  and  abscesses  to  be  formed,  then  there  is  an 
expectoration  of  a  thick  pus,  which  is  occasionally  tinged 
with  blood,  emaciation,  debility,  and  that  peculiar  affection 
of  the  system  which  is  known  by  the  name  of  hectic  fever. 


The   symptoms   attending   the   large  brown  tubercle 
are  unknown  to  me. 


When  the  cells  qf  the  lungs  are  much  enlarged  in  their 


52  ,_ 

size,  persons  have  been  remarked  to  have  been  long  sub- 
ject to  difficulty  of  breathing,  more  especially  on  motion 
oi  the  body;  but  I  believe  no  symptom  is  at  present  known s 
by  which  this  disease  may  be  discriminated  from  some 
others  incident  to  the  chest. 


In  some  cases  in  which  the  lungs  have  been  converted 
into  a  substance  like  the  liver,  symptoms  have  been  ob- 
served similar  to  those  which  attend  inflammation  of  the 
lungs.  I  am  inclined  to  believe  that  this  appearance  of 
the  lungs  is  produced  by  an  extensive  extravasation  of 
coagulable  lymph  into  their  substance,  during  an  attack 
of  inflammation. 


When  earthy  concretions  are  formed  in  the  lungs, 
persons  are  more  or  less  subject  to  difficulty  of  breathing, 
and  a  cough.  Occasionally  some  of  these  concretions 
are  coughed  up,  together  commonly  with  a  little  blood ; 
and  by  this  circumstance  alone  can  this  disease  be  dis- 
tinguished from  some  others  which  are  incident  to  the 
chest.  This  state  of  disease  often  leads  to  phthisis. 


When  hydatids  are  formed  in  the  lungs,  they  produce 
a  cough,  difficulty  of  breathing,  and  some  frequency  of 
the  pulse.  They  are  occasionally  forced  up  by  a  violent 
fit  of  coughing ;  and  this  circumstance  only  can  discrimi- 
nate the  disease  in  the  living  body. 


53 


CHAPTER  V. 


DISEASED  APPEARANCES  OF  THE  THYROID  GLAND, 
THE  LARYNX,  AND  THE  PARTS  CONTAINED  IN  THE 
POSTERIOR  MEDIASTINUM. 

BEFORE  we  describe  the  diseased  appearances  of  the 
parts  which  are  contained  in  the  posterior  mediastinum, 
we  shall  take  notice  of  the  morbid  changes  to  which  the 
thyroid  gland  and  the  larynx  are  liable.  These  are  so 
closely  connected  with  the  trachea,  that  a  description  of 
their  morbid  changes  could  not  be  introduced  so  properly 
in  any  other  place. 

Inflammation  of  the  Thyroid  Gland. 

The  thyroid  gland  is  sometimes  attacked  with  common 
inflammation,  but  this  happens  rarely.  There x  are  no 
peculiar  causes  acting  upon  it  to  produce  inflammation, 
and  it  would  seem  to  be  as  little  liable  to  be  affected  with 
this  disease,  as  any  gland  in  the  body.  When  the  thyroid 
gland  is  inflamed,  it  exhibits  the  common  appearances 
which  take  place  in  the  inflammation  of  the  substance  of 
other  parts.  Its  blood  vessels  are  enlarged  in  their  size, 
and  the  number  of  branches  which  are  capable  of  con- 
taining the  red  globules  of  blood  is  increased.  Hence  it 
appears  much  more  vascular  than  in  a  natural  state.  It  is 
increased  in  its  bulk,  and  feels  considerably  firmer  to  the 
touch  than  when  healthy ;  and  these  effects  are  produced 
partly  by  the  increased  quantity  of  blood  which  is  circu- 


54 

iating  through  it,  and  partly  by  the  extravasation  of  co- 
agulable  lymph,  and  perhaps  of  blood  into  its  substance. 

Bronchocele. 

The  morbid  change  of  structure  to  which  the  thyroid 
gland  is  most  liable,  is  that  swelling  of  it  called  bronchocele. 
This  is  apt  to  take  place  in  different  individuals  of  the 
same  family,  and  women  are  more  liable  to  be  affected 
with  it  than  men.  It  is  more  prevalent  in  some  districts 
of  countries  than  in  others,  and  those  where  it  is  most 
prevalent  are  mountainous. 

The  swelling  of  the  thyroid  gland  in  bronchocele  often 
increases  to  a  very  large  size,  and  sometimes  grows 
irregularly,  forming  projecting  tumours  upon  the  anterior 
part  of  the  neck.  This  irregularity  of  growth  is  more 
common  in  that  part  of  Savoy,  where  the  disease  is 
endemial,  than  in  Great  Britain. 

When  a  section  is  made  of  the  thyroid  gland  affected 
with  this  disease,  it  is  found  to  consist  of  a  number  of 
cells  which  contain  a  transparent  viscid  fluid.  These 
cells  vary  in  their  size  in  different  parts  of  the  same  gland, 
and  in  different  swellings  of  the  same  kind  in  different 
individuals.  Some  of  them  are  so  large  as  to  be  able  to 
contain  a  small  pea,  but  most  of  them  are  of  a  smaller 
size.  The  viscid  fluid,  when  the  gland  has  been  pre- 
served for  some  time  in  spirits,  is  changed  into  a  trans- 
parent jelly.  From  this  account  of  the  morbid  change  of 
structure  which  takes  place  in  bronchocele,  it  seems  not 
unreasonable  to  suppose  that  the  swelling  depends  upon 
a  vitiated  and  increased  secretion  in  the  gland.  The  se- 
cretion being  in  large  quantity,  gradually  distends  the 
cells,  increasing  thereby  their  capacity,  and  this  enlarge- 
ment of  the  cells  forms  the  general  swelling  of  the  gland. 


Scirrhous  of  the  Thyroid  Gland. 

The  thyroid  gland  sometimes  becomes  scirrhous,  but 
is  not  so  liable  to  this  disease  as  some  other  glands  of  the 
body.  When  it  is  affected  by  this  disease,  it  becomes 
enlarged  in  its  size,  but  not  to  any  considerable  degree, 
and  is  hard  to  the  feeling.  When  a  section  is  made  of 
it,  it  is  found  to  consist  of  a  solid  substance,  with  very- 
little  of  that  cellular  structure  which  is  so  strongly  marked 
in  bronchocele. 

This  gland  is  apt  to  become  swelled  and  hard  when 
ulcers  are  formed  at  the  upper  end  of  the  oesophagus. 
This  effect  is  sometimes  produced  by  the  ulcer  of  the 
oesophagus  spreading  to  the  thyroid  gland.  The  same 
change,  however,  has  been  observed  to  take  place  where 
the  ulcer  had  not  reached  so  far,  and  where  the  gland  was 
entire.  This  might  lead  to  the  opinion,  that  some  ducts 
of  communication  exist  between  the  thyroid  gland  and 
the  upper  part  of  the  oesophagus.  These  ducts  have  been 
supposed  by  several  anatomists,  but  their  existence  has 
never  yet  been  demonstrated . 

The  Ihyroid  Gland  converted  into  Bone. 

The  thyroid  gLnd,  or  a  part  of  it  is  occasionally  changed 
in  old  people  into  a  bony  mass,  but  this  disease  is  of 
rare  occurrence.  It  is  commonly,  I  believe,  a  disease  of 
no  consequence;  but  it  is  reasonable  to  think,  that  the 
bony  mass  by  an  irregular  growth  might  in  some  in- 
stances so  irritate  the  larynx,  or  the  upper  part  of  the 
trachea,  as  to  produce  inflammation  and  ulceration  of  these 
parts,  and  to  prove  ultimately  fatal. 


Larynx. — The    Cartilages   of  the    Larynx    converted 

into  Bone. 

The  cartilages  of  the  larynx  sometimes  become  bony, 
either  at  the  middle  or  a  more  advanced  period  of  life. 
When  the  disposition  to  form  bony  matter  in  the  larynx 
is  not  very  strong,  portions  of  the  thyroid  cartilage  only 
are  converted  into  bone;  but  when  the  disposition  is 
powerful,  then  all  the  cartilages  are  changed  into  a  bony 
substance.  When  this  is  the  case,  they  become  liable  to 
any  changes  which  might  take  place  in  ordinary  bone. 
Accordingly,  some  of  these  cartilages  so  changed  into 
bone  have  been  known  to  exfoliate,  and  to  be  thrown  out 
by  a  violent  fit  of  coughing  or  vomiting.  Dr.  Hunter 
had  an  opportunity  of  knowing  an  instance  where  the 
cricoid  cartilage,  being  converted  into  bone,  was  sepa- 
rated by  exfoliation,  and  afterwards  coughed  up.  It  is 
not  to  be  understood  from  what  has  been  said,  that  the 
cartilages  of  the  larynx,  when  changed  into  bone,  are 
more  liable  to  become  dead  and  exfoliate  than  the  com- 
mon bones  of  the  body.  The  instances  in  which  they 
have  been  known  to  exfoliate  are,  I  believe,  extremely 
rare. 

Ulcers  in  the  Cavity  of  the  Larynx. 

The  inner  membrane  of  the  larynx  is  very  apt  to  be 
inflamed,  and  this  generally  accompanies  the  inflammation 
of  the  inner  membrane  of  the  trachea,  as  we  shall  have 
occasion  to  mention  afterwards.  Sometimes,  however, 
an  inflammation  shall  take  place  which  is  confined  to  the 
cavity  of  the  larynx,  and  it  shall  occasionally  advance  to 
suppuration  and  ulceration.  Of  this  I  have  known  seve- 


ral  instances.  Suppuration  is  most  apt  to  take  place  in 
the  sacculi  laryngis:  and  the  ulcers  which  I  have  seen 
there,  are  sometimes  attended  with  a  scrofulous  thickening 
of  the  surrounding  parts. 

Diseased  App  earances  of  the  Parts  contained  in  the 
Posterior  Mediastinum. 

By  the  posterior  mediastinum,  is  meant  that  space 
which  lies  between  the  laminae  of  the  pleura,  that  pass  from 
the  root  of  the  lungs  to  each  side  of  the  spine.  The 
space  is  of  considerable  size,  and  contains  a  portion  of 
the  trachea  arteria,  of  the  oesophagus,  of  the  thoracic  duct, 
of  the  descending  aorta,  and  the  vena  azygos,  besides 
some  absorbent  glands. 

Diseased  Appearances  of  the  Trachea. 

The  inner  membrane  of  the  trachea  is  not  uncommonly 
inflamed  to  a  greater  or  less  degree,  In  this  state  it  is 
crowded  with  minute  florid  vessels,  which  give  it  a  gene- 
ral  appearance  of  vascularity.  When  there  is  no  in- 
flammation, it  appears  in  the  dead  body  a  white  pulpy 
membrane,  and  there  are  rarely  to  to  be  seen  any  red 
vessels  ramifying  in  it.  While  the  inner  membrane  is 
inflamed,  the  secretion  from  its  glands  is  very  much  in- 
creased, and  therefore  its  cavity  is  found  a  good  deal  filled 
with  a  mucous  fluid;  even  pus  is  sometimes  formed,  and 
both  fluids  are  mixed  with  globules  of  air.  This  is  the 
state  of  the  trachea  in  a  very  violent  catarrh,  and  also  in 
some  cases  where  there  are  scrofulous  abscesses  of  the 
lungs:  the  same  appearances  are  also  observable  in  the 
inner  membrane  of  the  larynx, 
H 


58 


Appearances  of  the  Trachea  in  the  Croup. 

When  the  inner  membrane  of  the  trachea  is  inflamed^ 
it  is  sometimes  lined  with  a  layer  of  a  yellowish  pulpy 
matter.  This  does  not  adhere  firmly  to  the  inner  mem- 
brane, but  may  be  easily  separated.  It  extends  from  the 
upper  part  of  the  cavity  of  the  larynx,  into  the  small 
branches  of  the  trachea,  which  are  distributed  through 
the  substance  of  the  lungs.  There  is  at  the  same  time 
a  good  deal  of  mucus  in  the  trachea  and  its  branches, 
together  with  a  mixture  of  pus.  This  is  the  appearance 
of  the  inside  of  the  trachea,  in  patients  who  have  died  from 
the  croup. 

Polypus. 

The  trachea  and  its  branches  are  sometimes  lined  with 
a  layer  of  a  yellowish  or  whitish  matter,  forming  a  sort  of 
tube,  which  is  applied  to  the  inner  surface  loosely.  It 
has  not  occurred  to  me  to  see  any  instance  of  it  in  the 
dead  bodies  which  I  have  examined;  but  I  have  seen 
several  examples  of  it  in  preparations.  The  inner  mem- 
brane of  the  trachea  seems  to  be  perfectly  natural,  and  the 
layer  of  adventitious  membrane  resembles  exactly  the 
coagulable  lymph  which  is  formed  in  other  parts  of  the 
body;  I  have  therefore  no  doubt  of  its  being  that  sub- 
stance. Since  this  disease  (which  is  called  polypus)  lasts 
for  a  long  time,  and  is  not  attended  with  symptoms  of 
inflammation,  it  appears  probable  that  the  vessels  of  the 
inner  membrane  of  the  trachea  possess  a  power  of  sepa- 
rating the  coagulabie  lymph  from  the  blood,  and  that  this 
disease  consists  in  a  peculiar  action  of  these  vessels. 

The  trachea  is  sometimes  filled  with  a  solid  substance. 


59 

of  the  same  kind  with  what  we  have  described.  Of  this 
I  have  only  seen  one  instance,  and  it  occurs,  I  believe, 
much  more  rarely  than  the  other. 

The  tubular  substances  which  are  thrown  out  from  the 
trachea  in  coughing,  and  which  constitute  the  most  or- 
dinary form  of  polypus,  were  considered  formerly,  by 
some  anatomists  of  distinguished  reputation,  as  blood 
vessels.  It  is  singular  that  they  should  have  paid  so  little 
attention  to  the  appearance  of  these  tubular  substances  as 
to  have  mistaken  them  for  blood  vessels;  and  it  is  still 
more  singular,  that  it  should  never  have  occurred  to  them 
upon  reflection,  that  blood  vessels  of  such  a  size  could  not 
be  coughed  up,  without  a  very  large  quantity  of  blood 
passing  along  with  them. 

A  more  modern  opinion  about  the  nature  of  these  tubu- 
lar substances  has  been,  that  they  consist  of  dried  mucus. 
This,  although  more  plausible  than  the  former,  is  equally 
ill  founded.  The  mucus  which  is  secreted  by  the  inner 
membrane  of  the  trachea,  is  exactly  of  the  same  kind 
with  that  secreted  by  the  inner  membrane  of  the  nose. 
Every  person  is  acquainted  with  the  appearance  of  the 
mucus  of  the  nose  when  dried.  The  mucus  of  the 
trachea,  when  dried,  would  have  the  same  appearance. 
The  tubular  substances  coughed  up  in  polypus  of  the 
trachea,  present  an  appearance  to  the  eye  very  different, 
and  (as  has  been  already  observed)  look  exactly  like  the 
coagulable  lymph.  The  influence  of  the  air  in  drying 
the  mucus  would  seem  to  extend  but  a  little  way  from 
the  external  surface  of  the  body,  for  the  mucus  is  fluid 
in  the  posterior  nostrils. 


60 


Trachea  sclrrhous. 

The  trachea  I  have  seen  narrowed  in  its  diameter  for 
two  or  three  inches,  thickened  in  its  substance,,  and  upon 
the  inner  membrane  were  formed  a  number  of  little  hard 
tubercles.  This  state  of  the  trachea  was  accompanied 
with  a  scirrhous  affection  of  some  absorbent  glands,  which 
closely  adhered  to  it;  and  it  appeared  to  me  that  the 
disease  in  the  glands  had  spread,  so  as  to  affect  the 
trachea. 

Kings  of  the  Trachea  ossified. 

The  cartilaginous  rings  of  the  trachea  occasionally  be- 
come ossified.  When  the  ossification  is  inconsiderable, 
the  function  of  the  trachea  will  hardly  be  affected  by  it ; 
but  where  the  rings  are  entirely  ossified,  the  flexibility 
of  the  trachea  must  be  much  lessened,  and  its  cavity  will 
not  admit  of  being  so  much  contracted  as  in  the  healthy 
state,  by  the  action  of  the  muscular  fibres,  which  form  a 
part  of  its  structure.  In  consequence  of  this  the  mucus 
which  is  occasionally  accumulated  will  not  be  so  readily 
expelled  by  coughing,  and  probably  the  air  will  not  be 
thrown  out  in  so  small  a  column,  nor  with  so  much  mo- 
mentum. 

Ulcers  of  the  Trachea. 

The  trachea  is  doubtless  liable,  like  other  parts  of  the 
body,  to  the  process  of  ulceration,  from  causes  acting 
immediately  upon  itself;  but  in  the  instances  which  I 
have  seen,  the  ulceration  has  been  connected  with  ulcera- 
tion of  the  oesophagus.  As  the  oesophagus  is  more  liable 
to  this  disease,  it  is  probable  that  in  such  cases  the  ulcera* 


61 

tion   has   begun  in  the  oesophagus,  and  spread  to  the 
trachea. 

Diseased  Appearances  of  the  (Esophagus. 

The  oesophagus  is  frequently  lined  with  a  layer  of  the 
coagulable  lymph,  which  is  continued  from  the  cavity  of 
the  mouth. 

This,  it  is  said,  sometimes  extends  over  the  whole 
intestinal  canal;  but  I  believe  this  appearance  to  be  ex- 
tremely rare,  and  it  commonly  terminates  at  the  lower 
end  of  the  oesophagus.  The  inner  membrane  of  the 
mouth  is  at  the  same  time  much  more  vascular  than  in  its 
natural  state,  shewing  a  deep  red  colour;  but  in  exami- 
nations after  death  the  appearance  of  greater  redness  is 
sometimes  scarcely  observable  in  the  oesophagus.  This 
disease  is  known  under  the  name  of  aphthae,  and  is  much 
more  often  to  be  observed  in  the  living  than  the  dead  body. 

Spasmodic  Stricture  of  the  (Esophagus. 

The  oesophagus  is  liable  to  stricture,  produced  by  the 
contraction  of  its  muscular  fibres  at  some  particular  part. 
This  disease  is  most  common  in  women  whose  constitu- 
tions are  delicate  and  much  subject  to  nervous  influence. 
When  such  a  disease  is  examined  in  the  dead  body,  the 
oesophagus  is  found  to  be  more  or  less  contracted  in  some 
part  of  it,  and  it  feels  harder  than  usual,  as  happens  to  all 
muscles  in  a  contracted  state.  There  is  no  appearance 
of  diseased  structure  usually  combined  with  it.  I  can 
suppose,  however,  that  this  contraction  might  lay  the 
foundation  of  a  permanent,  and  even  a  fatal  disease.  The 
muscular  fibres  of  the  oesophagus  might  so  press  on  the 
inner  membrane,  as  to  excite  inflammation  in  it,  which 


62 

might  advance  to  suppuration,  and  would  most  probably 
terminate  fatally. 

Stricture  from  the  Puckering  of  the  inner  Membrane  of 
(Esophagus. 

I  once  saw  a  very  unusual  stricture  of  the  oesophagus. 
It  consisted  in  its  inner  membrane  being  puckered  together, 
so  as  to  form  a  narrowness  of  the  canal  at  a  particular 
part,  which  would  hardly  allow  a  common  garden  pea  to 
pass.  There  was  no  appearance,  however,  of  diseased 
structure  in  the  inner  membrane  which  was  so  contracted, 
and  the  muscular  part  of  the  oesophagus  surrounding  it 
was  perfectly  sound.  I  know  that  this  disease  was  very 
slow  in  its  progress,  for  the  person  in  whom  it  took  place 
had  been  for  many  years  affected  with  a  difficulty  of 
swallowing,  and  could  only  swallow  substances  of  an 
extremely  small  size, 

Stricture  attended  with  Ulcer. 

The  most  common  appearance  of  disease  in  the  oesopha- 
gus, is  that  of  an  ulcer  in  its  cavity.  Ulcers  of  the  oeso- 
phagus are  sometimes  of  a  common  nature,  but  most 
frequently  they  are  attended  with  a  scirrhous  affection. 
When  they  arise  from  common  inflammation,  the  structure 
of  the  oesophagus  immediately  surrounding  the  ulcer  is 
but  little  thickened,  and  there  is  the  appearance  of  the 
usual  erosion  in  ulcers.  When  the  ulcer  is  of  a  scirrhous 
nature,  ihe  oesophagus  in  the  neighbourhood  is  very  much 
thickened,  and  is  very  hard  in  its  texture.  When  this 
texture  is  examined,  it  either  consists  of  an  hard,  uni- 
formly fleshy  substance,  or  this  is  a  little  intersected  by 
membranes,  or  it  is  gristly.  Under  such  circumstances 


63 

the  canal  of  the  oesophagus  is  always  more  or  less  narrow- 
ed, and  in  some  cases  is  almost  wholly  obliterated.  It  is 
worthy  of  remark,  that  these  ulcers  happen  most  fre- 
quently, either  immediately  under  the  pharynx,  or  near 
the  cardia. 

Any  substance  capable  of  irritating  the  inner  mem- 
brane of  the  oesophagus,  by  having  sharp  hard  projections, 
will  doubtless  be  more  likely  to  affect  the  oesophagus, 
where  it  first  enters  into  it.  In  an  oesophagus,  therefore, 
predisposed  to  scirrhus,  such  an  accident  may  prove  an 
exciting  cause,  and  the  disease  will  more  frequently  take 
place  at  its  upper  end.  At  the  cardia  too,  there  is  a  pecu- 
liar arrangement  of  the  muscular  fibres,  which  are  capable 
of  acting  in  some  degree  like  a  sphincter,  and  which 
produce  on  many  occasions  a  narrowness  of  the  canal 
there.  This  will  render  the  oesophagus  at  the  cardia  more 
liable  to  be  injured  by  the  passage  of  any  hard  substance, 
and  may  ultimately  lay  the  foundation  of  a  scirrhous  ulcer. 
This  is  the  account  which  the  late  Dr.  Hunter  used  to 
give  of  the  frequent  situation  of  ulcers  at  the  upper  and 
lower  extremities  of  the  oesophagus,  and  it  seems  to  have 
great  weight.  It  happens,  however,  most  commonly  that 
ulcers  of  the  oesophagus  arise  spontaneously,  or  in  other 
words,  from  causes  within  itself  which  we  cannot  ascer- 
tain. When  an  ulcer  takes  place  at  the  upper  end  of  the 
oesophagus,  it  is  apt  to  spread  into  the  substance  of  the 
thyroid  gland.  In  this  case  the  gland  becomes  hard, 
enlarged,  and  ulcerated :  but  in  some  instances  it  has  been 
known  to  enlarge,  where  the  ulcer  of  the  oesophagus  had 
not  spread  so  far  as  to  reach  it. x 

(Esophagus  cartilaginous. 
A  portion  of  the  oesophagus  has  been  observed  by 


64 

some  anatomists  to  be  converted  into  cartilage,  and  to 
have  its  diameter  at  that  part  very  much  diminished  in 
size.* 

This  was  probably  only  a  strong  example  of  the  gristly 
texture  above  described. 

Fungus  in  the  Pharynx. 

I  have  seen  an  instance  of  a  fungus  arising  on  the  in- 
side of  the  pharynx  and  the  upper  end  of  the  oesophagus, 
which  is  to  be  considered  as  a  rare  disease.  When  cut 
into  it  appeared  to  have  a  fibrous  structure,  disposed  in 
some  measure  at  right  angles  to  the  inner  membrane  upon 
which  it  was  formed,  and  was  ulcerated  on  its  surface. 

Scrofulous  Swelling  in  the  Pharynx. 

It  has  occurred  to  me  likewise  to  see  a  scrofulous 
swelling  at  the  lower  end  of  the  pharynx  and  the  begin- 
ning of  the  (Esophagus.  When  cut  into  it  appeared  to 
consist  of  the  same  kind  of  matter  as  a  scrofulous  absorbent 
gland.  It  grew  upon  that  side  of  the  pharynx  which  is 
next  the  larynx,  and  the  patient  for  this  reason  had  not 
only  lost  almost  entirely  the  power  of  swallowing,  but 
was  not  able  to  speak  except  in  the  smallest  whisper. 

Pouch  formed  at  the  lower  end  of  the  Pharynx. 

The  pharynx,  at  its  lower  extremity,  has  been  known 
to  be  dilated  into  a  pouch  of  a  considerable  size,  which 
passed  behind  the  oesophagus.  This  may  be  supposed  to 
be  very  rare,  but  there  is  an  instance  of  it  preserved  in 
Dr.  Hunter's  collection.  The  pouch  in  this  case  began 
to  be  formed  in  consequence  of  a  cherry-stone  having 

*  Vid,  Bonet.  Tom.  II.  p.  32. 


65 

rested  there  for  some  time,  which  had  made  a  kind  of 
bed  for  itself.  It  remained  in  that  situation  for  three 
days,  and  then  was  brought  up  by  a  violent  fit  of  coughing. 
A  part  of  the  food  always  rested  afterwards  in  the  cavity 
made  by  the  cherry-stone,  by  which  it  was  gradually 
enlarged.  At  length,  in  the  course  of  about  five  years, 
the  cavity  was  enlarged  into  a  bag  of  considerable  size, 
sufficient  to  contain  several  ounces  of  fluid.  This  bag 
passed  down  a  good  way  behind  the  oesophagus,  and  the 
oesophagus  necessarily  acquired  a  valvular  communication 
with  it.  In  proportion  as  the  bag  enlarged,  this  valvular 
communication  would  become  more  and  more  complete, 
till  at  length  every  kind  of  food  must  have  rested  in  the 
bag,  and  could  not  pass  into  the  oesophagus.  In  this  way 
the  person  was  destroyed,  The  lower  end  of  the  pharynx 
is,  perhaps,  the  only  part  of  the  canal  where  such  an  acci- 
dent can  happen.  The  pharynx  is  not  contracted  gradu- 
ally, so  as  to  lose  itself  insensibly  in  the  oesophagus,  but 
contracts  itself  rather  suddenly  at  the  lower  end.  Hence 
a  little  recess  is  formed,  in  which  an  extraneous  body  may 
occasionally  rest.  This  would  be  most  apt  to  happen  at 
the  posterior  part;  so  that  if  the  recess  should  be  en- 
larged into  a  cavity,  it  would  generally  pass  behind  the 
oesophagus.  The  particulars  of  this  singular  case  have 
been  published  in  the  Medical  Observations.* 

The  descending  Aorta. 

There  is  hardly  any  other  disease  of  the  descending 
aorta  within  the  posterior  mediastinum,  than  its  enlarge- 
ment. This  will  sometimes  take  place  in  a  great  degree, 
and  is  attended  with  a  diseased  state  of  its  coats.  The 

*  See  Medical  Observations,  Vol.  Ill,  p.  85, 


66 

coats  become  irregularly  thickened,  and  more  readily 
divisible  from  each  other,  than  in  a  healthy  state.  Little 
thin  laminae  of  bone  are  frequently  formed  behind  the 
inner  membrane,  and  small  masses  of  curdly  matter  are 
deposited  there.  It  is  rare  that  this  part  of  the  aorta 
becomes  enlarged,  unless  there  be  a  general  disposition 
to  enlargement  over  the  arterial  system. 

The  Vena  Azygos  varicose. 

The  vena  azygos  is  very  seldom  diseased.  I  have 
seen  it,  however,  varicose,  and  very  much  enlarged.  This 
change  in  it  took  place  from  particular  circumstances. 
A  considerable  portion  of  the  vena  cava  inferior  had  be- 
come obliterated;  in  consequence  of  this,  the  usual  vena 
azygos,  together  with  an  uncommon  one  on  the  left  side, 
were  the  only  channels  through  which  the  blood  could 
return  by  a  circuitous  route  to  the  heart;  they  were  there- 
fore  necessarily,  from  the  impetus  of  the  blood,  much 
enlarged  in  size,  and  for  the  same  reason  likewise  varicose. 
This  case  I  have  more  particularly  described  in  the 
Medical  and  Chirurgical  Transactions/* 

Vena  Azygos  ruptured. 

The   vena  azygos  has  been  known  to  be   ruptured, 

when  very  much  distended  with  blood.f  Such  a  case 

has  not  come  under  my  own  observation,  and  I  believe 
it  to  be  very  uncommon. 

The  Thoracic  Duct  varicose. 
The  thoracic  duct  also  is  subject  to  very  few  diseases. 

*  See  p.  125;  &c.  Vol.  I. 

fVid.  Morgagni,  Epist.  XXVI.  Art.  29. 


67 

I  have  never  seen  any  other  except  that  of  its  being  very 
much  enlarged  and  varicose. 

In  the  instance  to  which  I  allude,  it  was  very  nearly  as 
large  as  the  usual  size  of  the  subclavian  vein,  but  nothing 
could  be  detected  in  the  neighbouring  parts,  capable  of 
accounting  for  this  appearance.  There  was  no  obstruction 
at  the  entrance  of  the  thoracic  duct  into  the  venal  system, 
which  might  naturally  have  been  expected.  This 
diseased  appearance  of  the  thoracic  duct  has  already  been 
taken  notice  of  by  Mr.  Cruikshank  in  his  Treatise  on  the 
Absorbent  System.* 

Thoracic  Duct  obstructed. 

The  thoracic  duct  has  been  known  to  be  obstructed 
by  an  earthy  matter  deposited  in  its  cavity. t  It  does  not 
necessarily  happen  when  the  thoracic  duct  is  at  some  part 
obstructed,  that  chyle  is  prevented  from  entering  into  the 
system  of  blood  vessels.  The  thoracic  duct  sometimes 
sends  off  one  or  more  considerable  branches,  which  unite 
again  with  the  principle  trunk.  If  tinder  such  circum- 
stances an  obstruction  should  take  place  in  a  part  of  the 
principal  trunk,  between  the  origin  and  termination  of 
those  branches,  no  bad  effect  would  follow;  one  or  more 
of  these  branches  would  become  enlarged,  and  convey 
the  chyle  in  its  full  quantity  to  the  blood. 

Thoracic  Duct  ruptured. 

The  thoracic  duct  has  also  been  known  to  be  ruptured; 
although  this  is  exceedingly  rare. 


*  See  Second  edition,  p.  207;  and  in  it  is  represented  in  an  engraving, 
Plate  V.  f  Vid .  Lieutaud,  Tom.  II.  p.  93. 


68 


Absorbent  Glands  scrofulous. 

The  absorbent  glands  in  the  posterior  mediastinum, 
as  well  as  in  every  other  part  of  the  body,  are  liable  to 
several  diseases.  The  most  common  morbid  affection  is 
scrofula.  In  this  case  they  are  frequently  a  good  deal 
enlarged,  and  sometimes  feel  a  little  softer  to  the  touch 
than  in  their  healthy  structure.  When  cut  into,  they 
sometimes  exhibit  very  much  the  natural  appearance ;  but 
it  is  more  common  to  find  that  some  of  them  contain  a 
white,  soft,  cheesy  matter,  mixed  with  a  thick  pus :  this 
is  the  most  decided  mark  of  scrofulous  affection.  When 
the  absorbent  glands  in  this  situation  are  very  much  en- 
larged, they  necessarily  produce  some  difficulty  of  breathing, 
both  by  pressing  on  the  lungs  and  the  trachea.  They 
may  occasion  also  some  difficulty  of  swallowing. 

Absorbent  Glands  scirrhous. 

I  have  seen  the  absorbent  glands  in  the  neighbourhood 
of  the  trachea  affected  with  scirrhus,  although  it  is  a  rare 
disease  in  them.  They  were  much  'enlarged  and  very 
hard  to  the  touch.  When  cut  into  they  exhibited  a  hard 
texture,  somewhat  intersected  by  membrane,  so  as  to 
resemble  what  is  called  scirrhus  in  other  parts  of  the  body. 
The  trachea  in  contact  with  these  glands  was  also  affected. 
In  this  case  the  thyroid  gland  was  scirrhous,  and  it  is 
probable  that  the  disease  spread  from  the  thyroid  to  the 
absorbent  glands,  and  so  to  the  trachea. 

Absorbent  Glands  bony. 

The  absorbent  glands  near  the  trachea  are  sometimes 
converted  into  a  bony  or  earthy  matter;  and  I  think  that 


69 

this  disease  is  more  common  in  the  absorbent  glands  at 
the  root  of  the  trachea,  than  in  any  other  part  of  the  body. 
These  glands  when  so  diseased,  by  pressing  against  the 
trachea  or  oesophagus,  occasionally  produce  ulcers  in  them. 

The  Anterior  Mediastinum. 

By  the  anterior  mediastinum,  is  meant  the  space  in- 
closed  between  the  laminas  of  the  pleura,  which  pass  from 
the  sternum  to  the  pericardium ;  it  contains  little  else  than 
cellular  membrane,  with  perhaps  a  small  portion  of  fat; 
and  in  the  younger  subject  the  thymus  gland. 

It  is  seldom  found  with  any  diseased  appearance  in  it. 
Abscesses  are  occasionally  formed  there,  but  rarely. 
Water  too  is  sometimes  found  in  the  cells  of  its  cellular 
membrane.  I  have  also  seen  air  accumulated  in  these 
cells. 

Fat  is  occasionally  deposited  in  the  mediastinum  in 
considerable  quantity.  When  the  quantity  is  very  large, 
it  has  been  known  to  disturb  the  functions  both  of  the 
heart  and  lungs. 

Scrofulous  tumours  have  also  been  known  to  be 
formed  in  the  anterior  mediastinum,  but  this  morbid  ap- 
pearance occurs  very  rarely.*  Two  or  three  small  ab- 
sorbent glands  are  situated  in  the  anterior  mediastinum, 
and  these  may  be  occasionally  enlarged  from  scrofula, 
but  I  do  not  recollect  to  have  seen  any  instance  of  this 
having  taken  place. 

Diseased  Appearances  of  the  Thymus  Gland. 
The  thymus  gland  is  subject  to  few  diseases,  and  is 

*  See  Portal's  Anatomic  Medicate,  Tom,  V.  p.  30. 


7t> 

t>nly  of  temporary  existence;  few  instances  therefore  of 
morbid  structure  have  been  observed  in  it. 

It  would  seem  to  be  very  little  disposed  to  common 
inflammation ;  therefore  abscesses  have  occurred  in  it  very 
rarely,  and  have  been  but  little  taken  notice  of  by  authors. 

It  is  more  liable  to  be  enlarged  in  its  size,  and  to 
become  hard  in  its  texture.  It  once  occurred  to  myself 
to  observe  an  instance  of  this  sort,  but  I  had  not  an 
opportunity  of  examining  it  very  minutely. 

Small  calculi  have  been  said  to  be  occasionally  formed 
in  the  thymus  gland.* 


SYMPTOMS. 

Inflammation  of  the  thyroid  gland  may  be  known  by  an 
increase  of  its  size  and  firmness,  by  a  pain  felt  in  it,  which 
is  increased  upon  pressure,  and  which  is  probably  also 
increased  during  the  act  of  swallowing.  It  may  be  dis- 
tinguished from  some  other  swellings  of  this  gland,  as 
for  instance  from  bronchocele,  by  its  rapid  progress,  by 
the  feeling  of  pain,  and  by  its  not  increasing  to  a  very 
large  size. 

It  is  worth  while  to  remark,  that  practitioners  ought 
to  be  particularly  cautious  to  prevent  inflammation  of  the 
thyroid  gland  from  advancing  to  suppuration.  If  it  should 
suppurate,  and  the  pus  be  evacuated  externally,  there 
will  be  a  scar  in  the  neck;  and  if  it  should  point  internally, 

*  See  Dr.  Soemmering's  German  Translation,  p.  61. 


71 

it  will  probably  make  its  way  into  the  cavity  of  the  larynx 
or  the  trachea,  and  suffocate  the  patient.  There  is  a 
preparation  in  Dr.  Hunter's  collection,  shewing  this  fatal 
termination  of  inflammation  in  the  thyroid  gland.  Every 
means  should  be  attempted  to  make  the  inflammation 
terminate  in  resolution.  When  inflammation  of  the  sub- 
stance of  any  part  terminates  in  resolution,  the  blood 
vessels  gradually  return  to  their  natural  mode  of  action, 
and  their  natural  size :  the  deep  seated  absorbents  are  at 
the  same  time  excited  to  an  increased  exertion  so  as  to 
remove  the  blood  and  the  coagulable  lymph  which  had 
been  extravasated  during  the  inflammation.  This  is  one 
of  the  chief  uses  of  the  absorbent  vessels  which  are  dis- 
tributed through  the  substance  of  parts.* 


Bronchocele  may  be  distinguished  from  other  swellings 
of  the  thyroid  gland,  by  its  slow  growth,  by  the  size  at 
which  it  is  capable  of  arriving,  by  its  want  of  pain,  by  its 
commonly  occurring  at  an  early  period  of  life,  by  the 
sensation  it  yields  to  the  touch,  which  is  that  of  more  or 

*  In  the  reduction  of  some  of  the  deeper  seated  parts  of  the  body  from  a 
state  of  enlargement  to  their  natural  size,  there  is  a  strong  proof  of  a  consent 
or  sympathy  existing  between  the  superficial  and  deeper  seated  absorbent 
vessels.  When,  for  instance,  a  swelled  testicle  is  reduced  to  its  natural  size  by 
rubbing  mercurial  ointment  upon  the  surface  of  the  scrotum  which  covers  it, 
it  cannot  be  supposed  that  any  part  of  the  ointment  comes  in  contact  with  the 
absorbent  vessels  belonging  to  the  substance  of  the  testicle ;  yet  these  ab- 
sorbents are  excited  to  an  increased  action  by  the  application  of  the  ointment, 
and  the  testicle  is  at  length  reduced  to  its  natural  size.  This  effect  would 
seem  only  capable  of  being  explained  upon  the  principle  of  a  consent  or  sym- 
pathy existing  between  the  absorbents  of  the  scrotum  and  the  absorbents  of 
the  substance  of  the  testicle,  by  which,  when  the  former  are  stimulated,  tin 
litter  arc  roused  to  an  increased  action, 


72 

less  firmness,  but  not  of  great  hardness,  and  by  the  health 
being  unaffected  by  it. 


Scirrhus  of  the  thyroid  gland  may  be  distinguished 
from  other  swellings  of  it,  by  its  great  hardness,  by  oc- 
casional darting  pains  in  the  gland,  and  by  this  affection 
being  most  apt  to  occur  in  persons  of  an  advanced  age. 
The  swelling  likewise  in  scirrhus  of  the  thyroid  gland  is 
seldom  so  large  as  in  bronchocele. 


Ossification  in  the  thyroid  gland  can  only  be  ascer- 
tained by  an  accurate  examination  of  the  part  affected.  If 
the  ossification  be  upon  the  surface  of  the  gland,  the  bony 
matter  will  be  distinctly  felt  under  the  skin ;  but  if  it  should 
be  deeply  seated,  it  will  be  felt  more  obscurely,  so  as  to 
leave  the  nature  of  the  disease  in  some  doubt.  When, 
however,  it  has  made  further  progress,  it  will  become 
perfectly  distinct. 


When  the  cartilages  of  the  larynx  are  converted  into 
bone,  the  voice  has  been  remarked  to  become  hoarse,  or 
sometimes  to  be  changed  into  a  whisper.  This  may  be 
easily  explained  by  the  cartilages  of  the  larynx  having  lost 
their  flexibility,  and  therefore  being  rendered  incapable  of 
those  finer  motions  which  it  is  reasonable  to  imagine  must 
have  considerable  influence  upon  the  voice.  In  the 


73 

cases  which  I  have  had  an  opportunity  of  examining,  the 
ligaments  which  join  the  cartilages  together  were  natural 
in  their  structure ;  had  they  been  changed  into  bone,  all 
the  motions  of  the  larynx  would  have  been  lost.  It 
would  then  have  been  useless  as  the  chief  instrument  of 
voice;  but  what  would  be  the  exact  effect  of  such  a 
change  upon  various  sounds  transmitted  through  the 
trachea  and  the  larynx,  it  is  extremely  difficult  to  deter- 
mine. In  some  instances  where  the  cartilages  of  the 
larynx  have  been  converted  into  bone,  there  has  occurred 
a  total  inability  of  swallowing,  which  destroyed  the  pa- 
tients. Upon  examination  after  death,  no  disease  was 
observable  either  in  the  pharynx  or  the  oesophagus.  This 
inability  of  swallowing  was  probably  produced  by  some 
of  the  ossified  cartilages  being  enlarged  posteriorly  by  a 
morbid  growth,  so  as  to  encroach  very  much  upon  the 
cavity  of  the  pharynx.* 


When  ulcers  have  taken  place  in  the  cavity  of  the 
larynx,  there  is  a  fixed  pain  in  the  situation  of  this  organ, 
difficulty  of  breathing,  and  the  patient  can  only  speak  in 
a  whisper.  This  state  of  the  larynx  is  accompanied  with 
more  or  less  of  symptomatic  fever.  • 


The  symptoms  which  attend  catarrh  are  too  generally 

*  This  occurred  in  a  case  described  by  Dr.  Travers,  of  Newark,  in  Part  I.  of 
the  Vllth  Volume  of  the  Medico-Chirurgical  Transactions,  p.  151  and  152. 
Dr.  Robertson  of  Greenwich  Hospital  had  observed  the  inability  of  swallowing 
5n  one  or  two  similar  cases  many  years  ago. 

K 


74 

known  to  require  being  mentioned.  When  there  is  & 
sense  of  soreness  in  this  disease,  passing  down  the  middle 
of  the  chesty  it  arises  from  a  considerable  inflammation  of 
the  inner  membrane  of  the  trachea.  The  inflammation 
soon  goes  off,  but  the  increased  secretion  from  the  glands 
of  the  trachea 'often  remains  for  a  good  while  afterwards. 

The  inflammation  of  the  inner  membrane  of  the  trachea, 
which  is  sometimes  to  be  found  in  consumptive  patients, 
continues  more  or  less  throughout  the  course  of  the  disease 
in  the  lungs. 


The  symptoms  of  the  croup  are,  symptomatic  fever, 
difficulty  of  breathing,  a  wheezing  or  croaking  noise  in 
inspiration,  a  hoarse  voice,  and  a  sort  of  ringing  sound 
during  coughing:  portions  of  a. whitish  membrane  and 
pus  are  at  the  same  time  occasionally  coughed  up.  It 
may  perhaps  be  reasonable  to  suppose  that  the  whitish 
membrane  is.formed  by  some  peculiar  action  of  the  blood 
vessels  of  the  inner  surface  of  the  larynx  and  the  trachea, 
which  is  superadded  to  inflammation.  In  common  in- 
flammation of  the  inner  surface  of  the  larynx  and  trachea, 
there  is  merely  an  increased  secretion  of  mucus,  or  some- 
times of  pus;  but  in  the  croup  an  adventitious  membrane 
is  always  formed.  This  gives  some  probability  to  the 
supposition  which  we  have  made;  and  it  may  perhaps 
serve  to  explain  why  the  croup  is  so  rarely  cured  by  the 
means  Which  are  known  to  remove  common  inflammation,. 


The  symptoms  which  attend  a  polypus  of  the  trachea 


75 

are,  difficulty  of  breathing,  a  dry  cough,  and  a  frequent 
pulse,  but  without  any  signs  of  inflammation.  These, 
however,  would  not  enable  physicians  to  discriminate  this 
disease  from  several  others,  if  portions  of  the  polypus  were 
not  frequently  coughed  up.  The  disease  is  apt  to  con- 
tinue for  a  great  length  of  time. 


The  symptoms  attending  spasmodic  stricture  of  the 
oesophagus  characterize  sufficiently  the  nature  of  the 
disease.  The  difficulty  of  swallowing  is  not  constant,  but 
occasional.  It  comes  on  and  goes  off*  suddenly,  and  these 
changes  are  frequent.  There  is  no  emaciation  of  the 
body,  and  the  person  generally  seems  to  be  in  good  health* 


The  stricture  of  the  oesophagus  which  depends  upon 
a  puckering  of  the  inner  membrane,  is  slow  in  its  progress. 
It  may  continue  for  a  great  many  years,  and  the  person 
seems  to  be  in  good  health,  except  for  the  difficulty  of 
swallowing.  The  difficulty  is  constant, '  which  will  dis- 
tinguish it  from  a  mere  spasmodic  contraction  of  the 
muscular  fibres  of  the  oesophagus. 


The  symptoms  which  belong  to  a  stricture  of  the 
(oesophagus  depending  on  a  scirrhous  thickening  and  ulcer> 
distinguish  it  sufficiently  from  the  other  two  diseases. 

The  difficulty   of  swallowing   is  small  at  first,   and 


76 

gradually  becomes  worse,  but  is  constant.  When  the 
disease  has  made  considerable  progress,  the  food  is  fre- 
quently rejected,  and  along  with  it  occasionally  there 
passes  up  some  pus.  The  pulse  at  first  is  natural,  but  in 
the  advanced  stages  of  the  complaint  is  frequent;  and 
towards  its  termination  the  body  becomes  extremely 
emaciated.  The  parts  in  the  neighbourhood  of  the  disease 
are  irritated  to  an  increased  secretion,  which  often  pro- 
duces a  cough  or  hawking.  Although  hardly  any  nourish- 
ment, towards  the  end  of  this  disease,  can  be  got  into  the 
stomach,  yet  the  feeling  of  hunger  is  described  as  not 
being  distressing. 


When  there  is  a  fungus  or  a  scrofulous  tumour  in  the 
cesophagus,  the  symptoms  correspond,  I  believe,  very  much 
with  those  of  the  scirrhous  stricture  of  the  oesophagus 
just  described. 


77 


CHAPTER  VI. 


DISEASED    APPEARANCES     WITHIN     THE    CAVITY     OF 
THE    ABDOMEN. 

Ascites. 

ASCITES,  or  dropsy  of  the  cavity  of  the  abdomen,  is 
a  very  frequent  disease,  and  is  not  confined  to  any  sex  or 
age.  I  have  seen  several  instances  of  it  in  children  under 
ten  years  old;  but  it  is  much  more  common  at  the  middle, 
and  the  more  advanced  periods  of  life.  It  is  also  more 
common  in  the  male  than  the  female  sex.  When  water 
is  accumulated  in  a  large  quantity  in  the  cavity  of  the 
abdomen,  the  superficial  veins  of  the  belly  are  generally 
a  good  deal  distended  with  blood,  which  probably  arises 
from  the  pressure  of  the  water  upon  the  deeper  seated 
veins;  but  this  is  sometimes  hardly  observable,  even  when 
the  accumulation  of  the  water  is  very  considerable.  The 
skin  at  the  navel  is  also  often  protruded,  yielding  easily  to 
pressure;  but  this  is  not  universally  the  case.  On  many 
occasions  the  protrusion  can  hardly  be  seen,  though  the 
water  be  accumulated  in  large  quantity.  In  opening 
into  the  cavity  of  the  abdomen,  a  larger  or  less  quantity 
of  an  aqueous  fluid  is  observed,  which  is  generally  of  a 
brownish  colour,  but  its  colour  varies  according  to  cir- 
cumstances. When  there  is  a  scirrhous  liver  accompany- 
ing the  dropsy,  the  water  is  commonly  of  a  yellowish  or 
greenish  colour.  This  arises  from  a  mixture  of  the  bile 
with  the  water,  and  under  such  circumstances  there  is 


78 

almost  always  a  jaundice  colour  of  the  skin.  I  have  seeu 
the  water  in  ascites  of  chocolate  or  coffee  colour;  but  this 
appearance  is  rare.  In  a  case  of  this  kind  which  I  ex- 
amined more  particularly,  the  water  was  thicker  than  that 
of  ascites  usually  is;  but  it  had  the  common  properties  as 
far  as  could  be  known  from  the  application  of  heat  and 
of  acids.  When  none  of  the  viscera  of  the  abdomen  are 
diseased  the  water  in  ascites  resembles  the  serum  of  the 
blood  in  its  colour,  as  well  as  in  its  other  properties. 

While  water  is  accumulated  in  the  cavity  of  the  ab- 
domen, the  intestinal  canal  is  frequently  found  to  be  some- 
what in  a  contracted  state;  but  often  too  this  is  not  ob- 
servable. In  many  cases  of  ascites  the  liver  is  diseased, 
being  hard  and  tuberculated,  as  we  shall  explain  particu- 
larly when  treating  of  the  diseases  of  the  liver.  In  some 
cases  too,  the  spleen  has  been  found  to  be  enlarged  and 
hard. 

Ascites  is  not  necessarily  connected  with  the  accumu- 
lation of  water  any  where  else  in  the  body;  but  it  frequently 
happens  that  it  is  accompanied  with  the  accumulation  of 
water  in  the  chest,  and  under  the  skin,  particularly  of  the 
lower  extremities. 

Chyle  in  the  Cavity  of  the  Peritoneum, 

Chyle  has  been  occasionally  observed  to  have  been 
effused  into  the  cavity  of  the  peritonaeum,  from  the  rupture 
of  some  lacteal  vessels;  but  this  morbid  appearance  has 
occurred  very  rarely.  In  the  cases  to  which  I  allude,  the 
mesenteric  glands  were  scrofulous,  and  some  of  the  lacteals 
were  ruptured,  probably  from  the  great  obstruction  to  the 
passage  to  the  chyle  through  these  glands.* 

*  See  Portal's  Anatomic  Medicale,  Tom.  V.  p.  115, 


Inflammation  of  the  Peritoneum. 

The  peritonaeum  is  not  uncommonly  inflamed,  although 
it  is  by  no  means  so  liable  to  this  disease  as  the  pleura. 
There  is  a  cause  of  inflammation  in  it  peculiar  to  women, 
which  depends  on  a  certain  state  of  the  womb  after  partu- 
rition ;  but  there  is  also  a  variety  of  causes  producing  it, 
which  are  equally  applicable  to  both  sexes,  so  that  it  is 
frequently  found  in  men,  and  also  in  women  who  have 
not  been  pregnant. 

When  inflammation  has  taken  place  in  the  peritonaeum, 
several  appearances  are  observable  in  opening  the  body. 
The  peritonaeum  is  thicker  than  in  its  natural  state,  more 
pulpy,  and  less  transparent;  and  it  is  crowded  with  a 
number  of  very  small  vessels,  containing  a  florid  blood. 
When  a  portion  of  the  inflamed  peritonaeum  is  separated 
from  the  abdominal  muscles,  there  is  commonly  no  ap- 
pearance whatever  of  the  inflammation  having  spread  into 
the  muscles;  but  where  the  peritonaeum  covers  the  in- 
testinal canal,  the  inflammation  is  sometimes  found  to  have 
penetrated  not  only  into  the  muscular  coat  of  the  intestines, 
but  even  into  the  villous  membrane.  The  reason  of  this 
difference  probably  is,  that  the  peritonaeum  is  less  con- 
nected with  the  abdominal  muscles  than  with  the  intestinal 
canal,  so  that  the  inflammation  passes  less  readily  from  the 
peritonaeum  to  the  former  than  to  the  latter  part. 

Inflammation  of  the  peritonaeum  is  sometimes  slight 
and  partial ;  at  other  times  is  great,  and  spread  over  the 
whole  membrane.  When  it  is  slight,  and  affects  that 
part  of  the  peritonaeum  which  is  connected  with  the  in- 
testinal canal,  it  often  forms  broad  surfaces  of  inflam- 
mation, which  run  like  bands  along  the  course  of  the 


80 

intestines,  and  are  bounded  by  the  contact  of  different 
portions  of  the  intestines  among  themselves.  In  this  case 
the  coats  of  the  intestines  are  not  thicker  than  usual,  the 
inflammation  being  slight,  and  confined  to  the  peritonaeum 
itself.  Where  the  inflammation  is  great,  the  intestines 
are  much  thicker,  and  more  massy.  This  evidently 
arises  from  the  greater  accumulation  of  blood  in  the  small 
blood  vessels,  as  well  as  from  the  extravasation  of  fluids 
into  the  substance  of  the  intestines,  in  consequence  of  the 
strong  inflammatory  action  of  the  vessels.  The  mesentery 
and  mesocolon  are  much  thicker  than  in  their  natural  state, 
and  there  is  also  a  remarkable  change  in  the  omentum. 
It  is  frequently  as  thick  as  a  person's  hand,  and  lies  as  a 
circumscribed  mass  along  the  great  curvature  of  the 
stomach.  The  principal  cause  of  this  change  in  these 
parts  is  the  extravasation  of  the  coagulable  lymph  into  the 
cellular  membrane  between  the  laminae  of  the  peritonaeum 
which  form  them. 

In  many  places  there  is  formed  a  layer  of  a  yellowish 
pulpy  matter,  gluing  different  portions  of  the  viscera 
together.  This  layer  is  sometimes  thin:  at  other  times  is 
of  considerable  thickness,  and  appears  to  be  the  coagulable 
lymph  of  the  blood.  There  is  also  a  considerable  quantity 
of  a  brownish  fluid  in  the  cavity  of  the  abdomen  resembling 
the  serum,  which  is  mixed  with  small  shreds  of  the 
coagulable  lymph,  and  sometimes  with  pus,  giving  it  a 
turbid  appearance.  The  quantity  of  the  coagulable 
lymph,  and  of  the  fluid,  is  sometimes  large,  in  proportion 
to  the  degree  of  the  inflammation.  In  some  instances, 
instead  of  serum  a  large  quantity  of  pus  is  found.  Air 
too  is  sometimes  accumulated  in  the  stomach  and  the 
intestinal  canal,  which  had  been  formed  in  the  progress  of 


81 

the  disease.  At  other  times  this  air  is  wanting.  The  ac- 
cumulation of  air  is  most  common  when  the  inflammation 
is  slight,  and  passes  in  bands  along  the  surface  of  the 
intestines. 

Adhesions  in  the  Cavity  of  the  Abdomen. 

When  there  has  been  inflammation  of  the  peritonaeum 
either  generally  or  partially,  sufficient  to  have  formed  a 
layer  of  coagulable  lymph,  and  the  patient  has  survived 
the  disease,  the  coagulable  lymph  is  changed  into  a  fine 
transparent  membrane,  which  is  the  membrane  of  ad- 
hesions. The  time  which  is  occupied  in  the  change  of 
the  coagulable  lymph  into  the  membrane  of  adhesions,  is 
not  very  long;  for  I  have  had  several  opportunities  of 
tracing  the  gradual  progress  of  the  change  from  the  one 
into  the  other,  while  the  inflammation  appeared  to  have 
been  recent.  This  membrane  consists  of  a  cellular  s*ib- 
stance,.  similar  to  the  general  cellular  membrane  of  the 
body,  and  has  a  moderate  share  of  vasculnrity.  It  does 
not  naturally  shew  many  vessels  large  enough  to  admit 
the  red  globules  of  the  blood ;  but  it  shews  its  vascularity 
upon  slight  degrees  of  inflammation,  or  when  its  vessels 
have  been  filled  with  the  fine  injection.  This  membrane 
is  capable  of  elongating  gradually  by  the  motion  of  the 
viscera  upon  themselves,  so  as  ultimately  to  be  attended 
in  general  with  very  little  inconvenience.  I  have  very 
often  had  an  opportunity  of  observing  these  adhesions, 
either  joining  all  the  viscera  of  the  abdomen  more  or  less 
together,  or  joining  some  particular  viscera  to  each  other. 

Scrofulous  Masses  adhering  to  the  Peritoneum. 
1  have  several  times  had  an  opportunity  of  observing  a 


white  soft  granulated  matter  adhering  universally  behind 
the  peritonaeum.  In  some  places  it  formed  a  mass  of 
considerable  thickness;  in  others,  it  was  scattered  in  single 
small  masses.  In  one  case  I  recollect  that  it  formed  a 
substance  as  thick  as  my  hand,  between  the  peritonaeum 
and  the  abdominal  muscles,  while  it  was  scattered  in  small 
separate  portions  in  the  mesentary  and  the  peritonaeum, 
covering  the  intestinal  canal.  The  omentum  I  have 
sometimes  seen  changed  into  a  cake  of  this  substance. 
The  matter  itself  appears  to  be  scrofulous,  for  it  resembles 
exactly  the  structure  of  a  scrofulous  absorbent  gland,, 
before  pus  is  actually  formed.  lam  not  at  all  certain  how 
jfar  this  appearance  of  disease  should  have  been  classed 
along  with  those  of  the  peritonaeum :  it  does  not  take  place 
(at  least  in  the  cases  which  I  have  seen)  in  the  peritonaeum 
itself  but  behind  it,  yet  at  the  same  time  adhering  to  it. 
It  appears,  however,  upon  the  whole,  to  be  placed  here 
with  more  propriety  than  it  could  have  been  any. where 
else. 

Cancerous  Tumours  adhering  to  the  Peritoneum. 

I  have  also  seen  some  small  cancerous  tumours  growing 
from  the  peritonaeum.  These  were  extremely  hard,  of  a 
^hi  e  colour,  and  resembled  exactly  in  their  structure  the 
cancerous  masses  which  are  formed  in  the  stamach.  What 
puts  the  appearance  1  allude  to  beyond  a  doubt,  is,  that 
in  the  same  body  I  found  a  cancerous  tumour  of  the 
stomach.  The  cancerous  tumours  of  the  peritonaeum 
were  not  at  all  connected  with  this  other,  but  were  in  that 
part  of  the  membrane  which  lines  the  recti  abdominis 
muscles,  nearly  opposite  to  the  region  of  the  stomach. 


83 


Cartilaginous  Excrescences  growing  from  the 
Peritoneum. 

In  one  case  I  have  seen  a  great  many  cartilaginous  ex- 
crescences  growing  from  the  peritonaeum.  They  were 
of  a  small  size,  viz.  most  of  them  not  larger  than  a  garden 
pea,  and  grew  from  every  part  of  the  membrane.  They 
were  a  little  softer  than  the  cartilages  which  cover  the 
extremities  of  the  bones,  but  had  the  true  structure  of 
cartilage. 

Steatomatous  Tumours  adhering  to  the  Peritoneum. 

Steatomatus  tumours  have  also  been  observed  adhering 
to  the  peritonaeum;  but  these  are  of  very  rare  occurrence.* 

Hydatids  in  the  Abdomen. 

Hydatids  have  occasionally  been  found  to  occupy  a 
portion,  or  even  the  whole  of  the  cavity  of  the  abdomen. 
In  such  cases  they  are  connected  with  the  viscera,  and 
chiefly  with  the  liver  or  spleen.  They  may,  however,  be 
attached  to  any  viscus  or  to  any  part  of  the  peritonaeum. 
This  appearance  of  disease  is  uncommon. 

Air  in  the  Cavity  of  the  Abdomen. 

Air  has  been  said  to  be  occasionally  accumulated  in  the 
cavity  of  the  abdomen,  while  little  or  none  is  contained  in 
the  intestines,  f  This  I  believe  to  be  a  very  rare  occur- 
rence. Air  is  not  unfrequently  accumulated  in  conside- 
rable quantity  in  the  intestinal  canal,  while  there  is  none 


*  See  Soenimering's  German  Translation,  p,  7P. 
f  Vid.  Lieutaud,  Tom.  I.  p.  433. 


tit  all   in  the   cavity  of  the  abdomen.     When   a  large 
quantity  of  air  is  accumulated  in  the  bowels,  they  become 
greatly  distended,   and   their  coats   proportionably   thin* 
By  the  bowels  lying  in  close  contact  with  the  peritonaeum 
which  lines  the  muscular  parietes  of  the  abdomen,  there 
is  the  same  feeling  of  distension  when  the  hand  is  pressed 
against  the  surface  of  the  belly,  the  same  quick  reaction 
upon  removing  the  hand,  and  the  same  hollow   sound, 
when  the  belly  is  struck  by  the  fingers,  as  if  the  cavity 
of  the  belly  itself  had  been  filled  with  air.     This  has 
probably  given  rise  to  the  opinion,  that  the  air  is  often 
contained  in    the    cavity    of  the   belly.     I   can   believer 
however,  that  air  may  on  some  occasions  be  accumulated 
in  the  cavity  of  the  belly,  but  this  is  very  uncommon. 
A  part  of  the  intestine  when  very  much  distended  with 
air  may  burst,  and  a  portion  of  the  air  may  escape  into  the 
cavity  of  the  belly;  or  the  small  arteries  of  the  peritonaeum 
may  secrete  air  in  the  same  manner  as  it  appears  to  be 
formed  by  the  inner  membrane  of  the  stomach  and  the 
intestines.     Portal  has  mentioned  a  remarkable  instance 
which  he  met  with  in  a  woman  about  fifty  years  of  age,  in 
whose  abdomen  after  death  he  found  a  large  quantity  of 
air,  not  accompanied  with  any  rupture  of  the  intestines, 
or  with   any  organic  disease   of  any  of  the  abdominal 
viscera.* 


SYMPTOMS. 

The  symptoms  which  belong  to  ascites  are  almost  toe 
well  known  to  require  being  mentioned.     There  is  conv 

*  S^ee  Portal's  ^natomie  Medicale,  Tom.  V.  p.  3. 


85 

monly  a  distinct  feeling  of  fluctuation  upon  applying  one 
hand  to  the  belly,  and  striking  it  with  the  other;  the  urine 
is  in  small  quantity,  and  of  a  deep  colour;  there  is  thirst, 
often  some  feeling  of  feverish  heat,  and  a  pulse  more 
frequent  than  in  health.  The  breathing  is  likewise  diffi- 
cult when  the  water  is  accumulated  in  very  large  quantity. 


The  symptoms  attending  inflammation  of  the  perito- 
naeum are  a  pain  in  the  abdomen,  together  with  some 
swelling  there,  and  a  great  sense  of  soreness  to  the  touch. 
The  bowels  are  often  costive,  the  pulse  is  frequent  and 
hard,  and  the  other  circumstances  of  symptomatic  fever 
are  strongly  marked.  When  the  inflammation  is  slight, 
I  have  known  the  pain  to  be  very  inconsiderable,  and  the 
pulse  to  be  little  increased  in  its  frequency,  so  that  in- 
flammation of  the  peritonaeum  had  not  been  suspected. 
Upon  examination,  however,  of  the  body  after  death,  no 
other  diseased  appearance  than  a  slight  inflammation  of  the 
peritonaeum  was  discoverable. 


There  are  no  symptoms  which  mark  the  existence  of 
adhesions  in  the  abdomen;  and  they  seem  to  be  attended 
in  general  with  no  inconvenience  to  the  functions  which 
are  carried  on  in  that  cavity.  If  however,  an  adhesion 
should  form  a  chord  crossing  a  portion  of  intestine,  and  so 
pressing  it,  as  to  interrupt  its  cavity,  it  might  produce  a 
fatal  obstruction. 


The  symptoms  which  belong  to  scrofulous  and  scirrhous 
tumours  of  the  peritonaeum  are  unknown  to  me. 

I  know  of  no  symptoms  produced  by  cartilaginous 
excrescences  growing  from  the  peritonaeum.  It  is  probable 
that  they  are  generally  not  observable,  or  not  capable  of 
being  discriminated. 


Whenhydatids  are  accumulated  in  large  quantity  in  the 
abdomen,  it  will  require  some  attention  to  distinguish 
this  disease  from  ascites.  It  may  be  distinguished,  how- 
ever, in  the  following  manner.  In  the  case  of  hydatids, 
the  feeling  of  fluctuation  upon  striking  the  belly  with  the 
hand  will  either  take  place  very  indistinctly,  or  not  at 
all;  whereas  in  ascites  attended  with  no  extraordinary 
symptoms,  it  is  always  distinct.  The  swelling  in  ascites 
is  always  uniform,  but  in  an  accumulation  of  hydatids 
it  will  be  more  or  less  unequal  In  hydatids  it  will  be 
found,  upon  enquiry  into  the  history  of  the  case,  that 
the  swelling  first  began  in  some  determined  place,  where- 
as in  ascites  there  is  a  gradual  swelling  of  the  whole  belly. 

It  will  be  more  difficult  to  distinguish  an  accumulation 
of  hydatids  from  a  dropsy  of  the  ovarium  than  from 
ascites.  The  distinction  between  the  two  diseases  would 
seem  only  capable  of  being  determined  by  an  accurate 
enquiry  into  the  history  of  the  case.  In  dropsy  of  the 
ovarium  the  swelling  is  first  perceived  on  the  side  of  the 
lower  part  of  the  belly,  and  gradually  increases  upwards, 
so  as  to  occupy  a  great  part  of  the  cavity  of  the  abdomen. 
As  hydatids  most  commonly  grow  from  the  liver,  the 


87 

swelling  in  this  case  will  generally  be  first  sensible  at  the 
upper  part  of  the  belly,  and  spread  downwards.  Hydatids, 
however,  may  be  formed  in  any  part  of  the  abdomen, 
and  therefore  were  they  to  begin  to  be  formed  at  the 
side  of  the  lower  part  of  the  belly,  it  seems  hardly  possi- 
ble to  distinguish  the  one  disease  from  the  other. 


88 


CHAPTER  VII. 


DISEASED   APPEARANCES  OF   THE   STOMACH* 

Inflammation. 

It  sometimes  happens,  although  not  very  frequently 
(unless  poisons  have  been  swallowed),  that  inflammation 
takes  place  in  the  stomach,  and  spreads  over  a  very  con- 
siderable portion  of  its  inner  membrane,  or  perhaps  the 
whole  of  it.  It  is  much  more  common  for  inflammation 
to  occupy  a  smaller  portion  of  the  stomach.  In  such 
cases  the  inflammation  is  generally  not  very  violent.  The 
stomach  upon  the  outside,  at  the  inflamed  part,  shews  a 
greater  number  of  small  vessels  than  usual,  but  is  com- 
monly not  much  crowded  with  them.  On  opening  into 
the  stomach,  it  is  found  to  be  a  little  thicker  at  the  in- 
flamed part,  the  inner  membrane  is  very  red  from  the 
number  of  small  florid  vessels,  and  there  are  frequently 
spots  of  extravasated  blood.  It  does  not  often  occur 
that  a  common  inflammation  of  the  stomach  proceeds  to 
form  pus,  or  to  terminate  in  gangrene. 

When  arsenic  has  been  swallowed  (which  is  the  poison 
most  frequently  taken)  the  stomach  is  affected  with  a 
most  intense  degree  of  inflammation.  Its  substance  be- 
comes thicker,  and  there  is  a  very  great  degree  of  redness 
in  the  inner  membrane,  arising  partly  from  the  very  great 
number  of  minute  vessels,  and  partly  from  extravasated 
blood.  Portions  of  the  inner  membrane  are  sometimes 
destroyed  from  the  violent  action  that  has  taken  place  in 


89 

consequence  of  the  immediate  application  of  the  poison. 
I  have  also  seen  a  thin  layer  of  coagulable  lymph  thrown 
out  upon  a  portion  of  the  inner  surface  of  the  stomach. 
Occasionally  too,  some  part  of  the  arsenic  is  to  be  seen 
in  the  form  of  a  white  powder,  lying  upon  different 
portions  of  the  inner  membrane.  I  have  been  informed, 
that  in  two  cases  where  arsenic  had  been  swallowed,  and 
had  destroyed  the  persons  by  producing  violent  inflamma- 
tion of  the  stomach,  ulcers  were  found  upon  examination 
after  death,  at  the  lower  end  of  the  rectum.  These 
persons  had  never  complained  of  any  disease  in  the  rectum 
previously  to  swallowing  the  arsenic,  and  were  apparently 
in  good  health.  This  circumstance  is  stated  from  good 
authority,  and  may  have  been  produced  by  some  of  the 
arsenic  having  passed  along  the  whole  track  of  the  in- 
testines,  and  being  ultimately  lodged  between  some  of 
the  folds  of  the  inner  membrane  of  the  rectum. 

Appearances  in  Hydrophobia. 

On  opening  the  bodies  of  persons  who  have  died  from 
hydrophobia,  the  inner  membrane  of  the  stomach  is 
frequently  found  inflamed  at  the  cardia,  and  its  great  end. 
The  inner  membrane  of  the  pharynx  and  the  oesophagus 
is  also  inflamed.  The  membrane  is  not  thickened  by  the 
inflammation,  but  the  inflammation  spreads  as  in  erysipelas, 
shewing  in  some  places  a  distinct  line  of  boundary.  This 
inflammation  is  commonly  not  violent,  and  is  sometimes 
hardly  observable. 

Ulcers  in  the  Stomach. 

Opportunities  occasionally  offer  themselves  of  observing 
ulcers   in   the    stomach.      These   sometimes    resemble 
M 


90 

/common  ulcers,  in  any  other  part  of  the  body,  but  frequently 
they  have  a  peculiar  appearance.  Many  of  them  are 
scarcely  surrounded  with  any  inflammation,  have  not 
irregular  eroded  edges  as  ulcers  have  generally,  and  are 
not  attended  with  any  particular  diseased  alteration  in  the 
structure  of  the  stomach  in  the  neighbourhood.  They 
appear  very  much  as  if,  some  little  time  before,  a  part 
had  been  cut  out  from  the  stomach  with  a  knife,  and  the 
edges  had  healed,  so  as  to  present  an  uniform  smooth 
boundary  round  the  excavation  which  had  been  made. 
These  ulcers  sometimes  destroy  only  a  portion  of  the 
inner  coat  of  the  stomarch  at  some  one  part,  but  occasion- 
ally they  destroy  a  portion  of  all  the  coats,  forming  a  hole 
in  the  stomach.  When  a  portion  of  all  the  coats  is  de- 
stroyed, there  is  sometimes  a  thin  appearance  of  the 
stomach  surrounding  the  hole,  which  has  a  smooth  surface, 
and  depends  on  the  progress  of  the  ulceration.  At  other 
times,  the  stomach  is  a  little  thickened  round  the  hole; 
and  at  other  tknes  still,  it  seems  to  have  the  common 
natural  structure. 

Scirrhus  and  Cancer  of  the  Stomach. 

This  affection  of  the  stomach  is  not  very  uncommon 
towards  an  advanced  period  of  life,  and  I  think  is  more 
frequently  met  with  in  men  than  in  women.  This  may 
probably  depend  upon  the  greater  intemperance  in  the 
one  sex  than  in  the  other. 

Scirrhus  sometimes  extends  over  almost  the  whole  of 
the  stomach,  but  most  commonly  it  attacks  one  part  of  it. 
The  part  which  is  affected  with  scirrhus  has  sometimes 
no  very  distinct  limit  between  it  and  the  sound  structure 
of  the  stomach,  but  most  commonly  the  limit  is  very  well 


91 

marked.  When  scirrhus  attacks  a  portion  of  the  stomach 
only,  it  is  generally  towards  the  pylorus.  The  principal 
reason  of  this  probably  is,  that  there  is  more  of  glandular 
structure  in  that  part  of  the  stomach  than  in  any  other; 
and  it  would  appear  that  glandular  parts  of  the  body  are 
more  liable  to  be  affected  with  scirrhus  than  other  parts. 

When  the  whole  stomach,  or  a  portion  of  it,  is  scirrhous, 
it  is  much  thicker  than  usual,  as  well  as  much  harder  in 
its  texture.  When  the  diseased  part  is  cut  into,  the 
original  structure  of  the  stomach  is  frequently  marked 
with  sufficient  distinctness,  but  very  much  altered  from 
the  natural  appearance.  The  peritonaea!  covering  of  the 
stomach  is  many  times  thicker  than  it  ought  to  be,  and 
has  almost  a  gristly  hardness.  The  muscular  part  is  also 
very  much  thickened,  and  is  intersected  by  numerous 
membranous  septa.  These  membranous  septa  are, 
probably,  nothing  else  than  the  cellular  membrane  in- 
tervening between  the  fasciculi  of  the  muscular  fibres, 
thickened  from  this  disease.  The  inner  membrane  is 
also  extremely  thick  and  hard,  and  not  unfrequently 
somewhat  tuberculated  or  irregularly  elevated  towards  the 
cavity  of  the  stomach. 

It  frequently  happens  that  this  thickened  mass  is  ulce- 
rated upon  its  surface,  and  then  a  stomach  is  said  to  be 
cancerous.  Sometimes  the  inner  membrane  of  the 
stomach  throws  out  a  process  which  terminates  in  a  great 
many  smaller  processes,  and  produces  what  has  been 
commonly  called  a  fungous  appearance. 

It  also  happens  that  the  stomach  at  some  part  looses 
entirely  all  vestige  of  its  natural  structure,  and  is  changed 
into  a  very  hard  mass,  of  a  whitish  colour,  with  some  ap- 
pearance of  membrane  intersecting  it:  or  it  is  converted 


into  a  gristly  substance,  like  cartilage  somewhat  softened. 
The  absorbent  glands  in  the  neighbourhood  are  at  the 
same  time  commonly  enlarged,  and  have  a  very  hard 
white  structure. 

Circumscribed  scirrhoits  Tumours  in  the  Stomach. 

I  have  seen  several  instances  of  a  scirrhous  tumour 
being  formed  in  the  stomach  about  the  size  of  a  walnut, 
while  every  other  part  of  it  was  healthy.  This  tumour 
has  most  frequently  a  small  depression  near  the  middle  of 
its  surface.  While  it  remains  free  from  irritation,  the 
functions  of  the  stomach  are  probably  very  little  affected 
by  it;  when,  however,  it  is  irritated,  it  must  occasion  very 
considerable  disorder  in  the  functions  of  the  stomach,  and 
may  perhaps  lay  the  foundation  of  a  fatal  disease. 

Pouch  formed  in  the  Stomach. 

A  part  of  the  stomach  is  occasionally  formed  into  a 
pouch  by  mechanical  means,  although  very  rarely.  I  have 
seen  one  instance  of  a  pouch  being  so  formed,  in  which 
five  halfpence  had  been  lodged.  The  coats  of  the 
stomach  were  thinner  at  that  part,  but  were  not  inflamed 
nor  ulcerated.  The  halfpence  had  remained  there  for 
some  considerable  time,  forming  a  pouch  by  their  weight, 
but  had  not  irritated  the  stomach  in  such  a  manner  as  to 
produce  inflammation  or  ulceration. 

Stricture  at  the  Pylorus. 

The  orifice  of  the  stomach  may  be  almost,  or  perhaps 
entirely,  shut  up  by  a  permanent  contraction  of  its  muscu- 
lar fibres,  either  at  the  cardia  or  pylorus.  This  is  likely, 
however,  to  occur  most  frequently  at  the  pylorus,  because 


93 

the  fibres  at  this  end  of  the  stomach  are  more  circular  in 
their  direction,  and  possess  a  stronger  contractile  power. 
Less  contraction  too,  at  the  pylorus,  will  produce  an  ob- 
struction in  the  canal,  than  at  the  cardia.  I  have  seen  one 
instance  of  this  contraction  at  the  pylorus,  which,  even 
there,  is  a  very  rare  disease.  The  contraction  was  so 
great  as  hardly  to  admit  a  common  goose  quill  to  pass 
from  the  stomach  into  the  duodenum,  and  it  had  pre- 
vented a  number  of  plumb  stones  from  passing,  which 
were  therefore  detained  in  the  stomach. 

Fungous  Tumdurs  obstructing  the  Pylorus. 

Some  instances  have  occurred  of  the  passage  of  the 
pylorus  being  obstructed  by  fungous  tumours  growing 
from  narrow  pedicles  attached  to  this  part  of  the  stomach. 
This  morbid  appearance,  however,  is  very  rare,  and  has 
not  fallen  under  my  own  observation.* 

Stomach  much  contracted^  or  much  enlarged* 

The  stomach  is  sometimes  found  so  contracted  through 
the  whole  of  its  extent  as  not  to  be  larger  than  a  portion 
of  the  small  intestine;  and  sometimes  it  is  enlarged  to 
much  more  than  its  ordinary  size.  Neither  of  these  ap- 
pearances is  to  be  considered  as  arising  from  disease. 
They  depend  entirely  on  the  muscular  fibres  of  the 
stomach  being  in  a  state  of  contraction  or  relaxation  at  the 
time  of  death.  It  happens,  I  think  more  frequently  that 
the  stomach  is  dilated  than  contracted. 

Stomach  distended  with  Air. 
The  stomach  is  very  commonly  found,  in  a  dead  body, 

*  See  Portal's  Anatomic  Medicale,  Tom.  V.  p.  205, 


94 

flaccid  and  almost  empty;  but  not  unfrequently  it  is  found 
more  or  less  distended  with  air:  this  air  may  have  been 
formed  after  death,  but  it  is  often  formed  during  life. 
When  this  is  the  case,  we  may  suppose  it  is  to  be  pro- 
duced by  a  new  chemical  arrangement  of  the  contents  of 
the  stomach;  but  it  also  frequently  happens  that  air  is 
separated  from  blood,  in  the  blood  vessels  of  the  stomach, 
and  poured  by  the  small  exhalents  into  its  cavity.  This 
has  been  more  particularly  taken  notice  of  by  Mr.  Hunter, 
in  his  essay  upon  Digestion,*  and  by  myself,  in  a  paper 
which  is  published  in  the  first  volume  of  the  Medical  and 
Chirurgical  Transactions.! 

Part  of  the  Stomach  dissolved  by  the  Gastric  Juice. 

In  looking  upon  the  coats  of  the  stomach  at  its  great 
end,  a  small  portion  of  them  there  appears  frequently  to  be 
thinner,  more  transparent,  and  feels  somewhat  more  pulpy 
than  is  usual;  but  these  appearances  are  seldom  very 
strongly  marked.  They  arise  from  the  gastric  juice 
resting  on  that  part  of  the  stomach  in  greater  quantity  than 
on  any  other,  and  dissolving  a  small  portion  of  its  coats. 
This  is  therefore  not  to  be  considered  as  the  consequence 
of  a  disease,  but  as  a  natural  effect,  depending  upon  the 
action  of  the  gastric  juice,  on  the  coats  of  the  stomach 
after  death.  When  the  gastric  juice  has  been  in  con- 
siderable quantity,  and  of  an  active  nature,  the  stomach 
has  been  dissolved  quite  through  its  substance  at  the  great 
end,  and  its  contents  have  been  effused  into  the  general 
cavity  of  the  abdomen.  In  such  cases  the  neighbouring 

*  See     Dr.    Hunters    Observations    on     certain     parts    of    the    Animal 
Economy,  p.  164. 
t  See  case  of  emphysema,  p.  202. 


95 

viscera  are  also  partially  dissolved.  The  instances, 
however,  of  so  powerful  a  solution  are  rare,  and  have 
almost  only  occurred  in  persons  who  while  in  good  health 
had  died  suddenly  from  accident.  If  the  powers  of  the 
stomach  were  little  impaired  by  diseases,  this  appearance 
of  the  stomach  after  death  would  be  very  common.  As, 
however,  they  are  very  much  injured  by  most  diseases, 
and  by  many  totally  destroyed,  this  appearance  very  seldom 
takes  place.  The  true  explanation  of  these  appearances 
was  first  given  by  Mr.  Hunter,  and  published  at  the 
request  of  Sir  John  Pringle,  in  the  Philosophical 
Transactions.* 

Fatty  Tumours  in  the  Stomach. 

Tumours  consisting  of  a  fatty  substance,  have  been 
sometimes  found  in  the  stomach  but  they  are  to  be  con- 
sidered as  a  very  rare  appearance  of  disease.  Ruysch 
relates  that  he  has  seen  a  tumour  from  the  stomach  of  a 
man  which  contained  hair,  together  with  some  dentes 
molares;  and  that  he  has  preserved  this  in  his  collection.! 

This  preparation  of  Ruysch  may  be  considered  as  ex- 
hibiting an  approach  to  the  formation  of  a  foetus  in  the 
human  stomach.  Two  cases  somewhat  similar  to  it,  but 
much  more  extraordinary,  because  the  developement  of 
the  ibetal  structure  was  much  more  perfect,  have  within 
a  few  years  occurred  in  this  country. J 

*  See  Philosophical  Transactions,  Vol.  62,  p.  447. 

fVid,  Ruysch,  Tom.  2.  Adversar.  Anatomicor.  Decad.  Tert. 

}  One  of  these  cases  was  published  about  thee  years  ago,  by  Mr.  Highmefre, 
Surgeon  at  Sherborne,  in  which  the  foetus  was  contained  in  a  cyst,  that  com- 
municated with  the  duodenum.  The  other  was  published  by  Mr.  Yonng,  in  the 
first  volume  of  the  Medico-Chirurgical  Transactions,  where  the  foetus  was  con. 
tained  in  a  cyst,  that  was  situated  between  the  laminae  of  the  transverse 
mesoQolon,  p.  234. 


96 


Calculi  in  the  Stomach. 

Calculi  with  different  appearances  have  been  described 
as  being  occasionally  found  in  the  stomach.  They  have 
never  come  under  my  own  observation,  and  are  to  be 
reckoned  very  uncommon.*  Most  of  these  calculi  have 
been  found  upon  examination  to  be  biliary,  and  had- been 
conveyed  from  the  duodenum  into  the  stomach  by  an 
antiperistaltic  motion  of  this  part  of  the  small  intestines. 

Morbid  Papilla  observed  in  the  Stomach. 

Papillae  and  pustules  somewhat  resembling  the  small- 
pox have  also  been  described  as  being  formed  on  the 
inner  membrane  of  the  stomach,  but  these  are  exceedingly 
rare.f 

Small-pox  Pustules  said  to  be  in  the  Stomach. 

Even  true  small-pox  pustules  have  been  said  to  be 
found  in  the  stomach  of  persons  who  died  from  this 
disease.  £  In  later  dissections, '  however,  this  appearance 
has  not  been  observed,  and  I  am  disposed  to  believe, 
where  it  has  been  thought  to  exist,  that  some  mistake  has 
been  made. 


SYMPTOMS. 

In  inflammation  of  the  stomach,  the  following  symptoms 
are  observed  to  take  place:  viz;  pain  in  the  epigastric 

*  Vid.  Lieutaud,  Tom.  I.  p.  17. 
f  Vid.  Lieutau  1,  Tom  1  p  23. 
•;  Vid.  Lieutaud,  Tom.  I.  p.  371. 


97 

region,  which  is  increased  when  any  thing  has  been 
swallowed,  vomiting,  often  hickup,  symptomatic  fever, 
with  a  small,  frequent,  and  hard  pulse,  and  a  feeling  of 
great  debility. 


When  a  person  has  been  poisoned  by  arsenic,  the 
following  symptoms  have  commonly  been  observed,  viz, 
vomiting,  great  thirst,  a  burning  feeling  in  the  stomach, 
severe  griping  pains,  purging  of  a  watery  or  viscid  matter, 
sometimes  of  blood,  a  sense  of  coldness,  especially  in  the 
extremities,  a  cold  sweat,  occasionally  paleness  of  the 
countenance,  the  countenance  often  swelled  and  flushed, 
often  faintness  and  languor,  sometimes  convulsions,  some- 
times palpitation  of  the  heart,  and  sometimes  vertigo.* 


Hydrophobia  is  sufficiently  characterized  by  the  horror 
which  the  patient  expresses  at  the  sight  of  any  fluid  that 
is  offered  to  him,  by  the  great  difficulty  experienced  in 
swallowing,  and  by  the  strong  alienation  of  mind  which 
often  accompanies  this  dreadful  disease. 


I  have  reason  to  believe  that  ulcers  of  the  stomach  are 
often  slow  in  their  progress.  They  are  attended  with 
pain,  or  an  uneasy  feeling  in  the  stomach,  and  what  is 

*  See  a  very  clear  account  of  the  symptoms  produce  by  swallowing  arsen& 
in  a  Treatise  upon  this  subject,  lately  published  by  Mr.  Marshall. 

N 


swallowed  is  frequently  rejected  by  vomiting.     Pus  and 
blood  are  likewise  occasionally  thrown  up  by  vomiting. 


Cancer  of  the  stomach  is  attended  with  a  sense  of  pain 
in  that  organ,  which  varies  a  good  deal  in  its  degree  in 
different  individuals.  What  is  swallowed  is  commonly, 
but  not  always,  rejected  by  vomiting,  and  there  is  fre- 
quently thrown  up  a  dark  coloured  fluid,  which  has  gene- 
rally been  compared,  in  its  appearance,  to  coffee  grounds. 
The  patient  becomes  at  length  emaciated,  and  the  counte- 
nance sallow;  the  pulse  at  the  beginning  of  this  dreadful 
complaint  is  natural,  but  towards  the  close  of  it  is  frequent, 
and  this  is  accompanied  with  the  usual  symptoms  of  hectic 
fever.  Where  the  person  is  much  emaciated,  and  the 
cancerous  swelling  is  situate^  near  the  pylorus,  or  along  a 
part  of  the  great  curvature  of  the  stomach,  it  may  be  felt, 
if  its  bulk  be  considerable,  by  a  careful  examination  with 
the  hand  in  the  living  body. 


The  accumulation  of  air  in  the  stomach,  is  accompanied 
with  an  unpleasant  feeling  of  distention  there,  and  a 
swelling  may  be  felt  externally  in  the  epigastric  region; 
wind  passes  up  by  the  oesophagus,  and  there  are  occasional 
pains  in  the  stomach  produced  by  a  spasmodic  contraction 
of  some  part  of  its  muscular  coat. 


CHAPTER  VIIL 


DISEASED   APPEARANCES  OF   THE   INTESTINES. 

Inflammation. 

THE  intestinal  canal  is  subject  to  inflammation  from  a, 
variety  of  causes,  and  therefore  we  have  frequent  oppor- 
tunities of  observing  its  effects  after  death.  When  a 
portion  of  intestine  is  inflamed,  there  is  spread  upon  its 
outer  surface  a  number  of  small  vessels,  many  of  which 
contain  florid  blood.  When  the  intestine  is  cut  into,  so 
as  to  exhibit  its  inner  membrane,  this  appears  highly 
vascular  from  the  small  vessels  of  the  villi  being  loaded 
with  blood,  and  a  few  spots  of  extravasated  blood  are 
frequently  to  be  seen  in  it.  In  inflammation  of  the  in- 
testines, the  peritonaeum  is  often  very  little,  or  not  at  all 
affected.  When,  however,  the  inflammation  is  very  great, 
the  peritonaeum  is  also  inflamed,  and  covered  with  a  layer 
of  coagulable  lymph.  I  have  likewise  seen,  in  violent 
inflammation,  scattered  portions  of  coagulable  lymph 
thrown  out  upon  the  surface  of  the  villous  membrane: 
this  however  is  very  uncommon.  The  intestine  is  at  the 
same  time  much  more  thick  and  massy  than  in  a  healthy 
state,  and  its  colour  is  sometimes  very  dark  from  a  large 
quantity  of  black  extravasated  blood.  This  state  of  the 
intestine  has  often  been  mistaken  for  mortification. 

It  very  commonly  happens  that  inflammation  of  the  in- 
testines advances  to  suppuration  and  ulceration  This 
takes  place  where  the  inflammation  is  confined  principally 


100 

to  the  inner  membrane  of  the  intestines.  The  ulcer  is 
formed  upon  the  inner  surface;  and  I  do  not  recollect  to 
have  seen  one  instance  where  the  ulcer  had  begun  upon 
the  outer  surface  of  the  intestines  and  had  spread  inwards. 
Ulceration,  however,  does  not  appear  to  be  so  common  in 
the  small  as  in  the  great  intestines.  When  it  takes  place 
either  in  the  one  or  the  other  intestine,  it  is  attended  with 
considerable  variety  in  its  appearance;  the  edges  of  the 
ulcer  have  sometimes  considerable  thickness :  and  some- 
times they  are  not  thicker  than  the  healthy  structure  of 
the  intestine;  the  edges  and  general  cavity  of  the  ulcer  are 
sometimes  ragged  and  at  other  times  they  are  smooth,  as 
if  a  portion  had  been  cut  out  from  the  intestine  with  a 
knife.  Sometimes  through  a  considerable  length  of  the 
intestine  (especially  if  it  be  the  great  one)  the  inner  mem- 
brane hangs  in  tattered  shreds,  occasioned  by  the  great 
ravage  of  the  ulceration.  I  have  also  seen  a  considerable 
portion  of  the  intestine  completely  stripped  of  its  inner 
membrane,  from  the  extent  of  this  process,  and  its 
muscular  coat  appeared  as  distinct  as  if  the  inner  mem- 
brane had  been  very  carefully  dissected  off.  In  the 
follicular  glands,  which  are  gathered  together  in  little 
oval  groups,  I  think  ulceration  occurs  more  frequently 
than  in  the  other  parts  of  the  intestine. 

When  ulceration  advances  very  actively,  it  sometimes 
eats  through  the  coats  of  the  intestine  entirely.  When 
this  is  the  case,  a  portion  of  the  contents  of  the  intestine 
occasionally  passes  into  the  general  cavity  of  the  abdomen, 
producing  inflammation  there.  This,  however,  does  not 
very  often  happen;  most  commonly  that  portion  of  the 
gut  where  the  ulcer  is  situated  adheres  by  inflammation 
to  some  other  portion,  or  to  a  neighbouring  viscus,  and  a 


101 

communication  is  formed  between  the  one  and  the  other. 
I  have  seen  communications  formed  in  this  manner 
between  the  rectum  and  the  bladder  in  a  male,  and  between 
the  rectum  and  the  vagina  in  a  female.  I  have  even  seen 
a  communication  formed  between  the  kidney  and  a  por- 
tion of  the  intestine  from  this  cause,  by  which  the  pus 
produced  in  the  kidney  was  evacuated  through  the  in- 
testine. Such  communications  are  the  means  of  preserving 
life  (although  in  a  very  uncomfortable  state,)  for  a  much 
longer  time  than  it  could  be,  were  the  matter  to  pass  into 
the  general  cavity  of  the  belly.  It  would  there  produce 
peritonaeal  inflammation,  which  would  soon  destroy.  The 
inner  membrane  of  the  intestines  is  more  disposed  to 
become  ulcerated,  than  the  inner  membrane  of  any  other 
canal  which  has  an  external  opening.  Thus  ulcers  are 
very  rare  in  the  inner  membrane  of  the  trachea  or  the 
urethra,  but  very  common  in  the  inner  membrane  both 
of  the  great  and  the  small  intestines.  It  is  difficult  to 
assign  a  satisfactory  reason  for  this  difference.  It  probably, 
however,  depends  upon  the  different  structures  and 
functions  of  these  parts.  There  is  a  good  deal  of  re- 
semblance between  the  structure  of  the  inner  membrane 
of  the  trachea  and  the  urethra.  The  secretion  of  the  one, 
likewise,  is  not  very  different  from  that  of  the  other.  The 
inner  membrane  of  the  intestines  has  a  structure  and 
secretion  peculiar  to  itself.  It  is  probable  that  upon 
these  circumstances  depends  its  greater  disposition  to 
ulcerate;  but  it  is  very  difficult  to  explain  how  this  should 
be  the  case. 

Inflammation  of  the  intestines  sometimes,  although 
rarely,  advances  to  mortification.  When  this  is  the  case, 
the  mortified  part  is  of  a  dark  livid  colour,  and  has  lost 


102 

its  tenacity;  it  is  in  this  state  very  easily  torn  through,  or 
the  fingers  will  pass  through  it  as  through  a  rotten  pear- 
The  want  of  the  natural  tenacity,  when  attended  with  the 
change  of  colour  which  we  have  mentioned,  is  the  only 
sure  criterion  of  a  part  being  mortified  in  examinations 
after  death.  A  portion  of  intestine  may  be  of  a  very 
dark  colour,  and  yet  may  not  be  mortified.  This  dark- 
ness of  colour  may  be  occasioned  by  a  large  quantity  of 
blood  extravasated  during  a  high  degree  of  inflammation, 
where  the  principle  of  life  is  maintained  in  full  vigour. 
Thus,  we  see  blood  effused  into  the  cellular  membrane 
under  the  skin,  producing  a  very  dark  appearance,  yet 
the  parts  are  quite  alive.  It  has  often  happened  too,  that 
a  very  dark  portion  of  intestine  has  been  returned  in  the 
operation  for  bubonocele,  and  yet  the  parts  have  recovered 
their  natural  functions.  This  could  never  have  happened 
if  the  black  portion  of  the  intestine  had  really  been 
mortified.  Under  such  circumstances,  the  mortified  part 
would  have  separated  from  the  living,  and  the  function 
of  the  gut  must  have  been  destroyed.  When  a  portion 
of  gut  has  been  for  some  time  mortified,  a  considerable 
quantity  of  air  is  formed,  which  is  accumulated  in  its 
cavity.  This  is  a  part  of  the  natural  process  which  takes 
place  in  all  dead  animal  substances.  I  have  known  an 
instance  where  a  large  portion  of  the  great  intestine  (viz. 
above  a  yard  of  it),  had  lost  its  living  principle,  and  was 
expelled  through  the  anus.  The  person  lived  about  three 
weeks  afterwards.* 

•  See  Medical  and  Chirurgical  Transactions,  Vol.  2.  p.  144, 


103 


Intus-Susceptio. 

This  is  not  a  very  uncommon  disease,  and  is  frequently 
fatal.  It  consists  in  a  portion  of  gut  passing  for  some 
length  within  another  portion,  and  dragging  along  with 
it  a  part  of  the  mesentery.  The  portion  of  gut  which  is 
received  into  the  other,  is  in  a  contracted  state,  and  is 
sometimes  of  considerable  length.  It  usually  happens 
that  an  upper  portion  of  intestine  falls  into  a  lower;  but 
the  contrary  likewise  occurs,  although  rarely.  Intus- 
su  sceptic  may  take  place  in  any  part  of  the  intestinal 
canal,  but  it  happens  most  frequently  in  the  small  in- 
testines, and  where  the  ileum  terminates  in  the  colon. 
In  this  last  situation,  it  appears  to  me  to  happen  more 
frequently  than  any  where  else.  This,  perhaps,  depends 
on  the  great  difference  in  size  between  these  two  portions 
of  intestine.  In  opening  bodies,  particularly  of  infants, 
an  intus-susceptio  is  not  unfrequently  found,  which  had 
been  attended  with  no  mischief:  the  parts  appear  perfectly 
free  from  inflammation,  and  they  would  probably  have 
been  easily  disentangled  from  each  other  by  their  natural 
peristaltic  motion.  At  other  times,  however,  so  large  a 
portion  of  the  gut  passes  within  another  portion  of  it  that 
cannot  be  disentangled,  and  the  passage  of  the  intestines 
is  obstructed,  without  any  possibility  of  its  being  set  free. 
This  is  the  fatal  state  of  the  disease,  is  sometimes 
attended  with  inflammation,  and  is  sometimes  without  it. 

Ruptures. 

A  portion  of  the  viscera  of  the  abdomen  frequently 
passes  out  of  that  cavity,  being  lodged  in  a  bag  of 
elongated  peritoneum ;  and  this  disease  is  called  a  rupture. 


104 

It  happens  most  commonly  from  some  sudden  and  violent 
concussion  of  the  body,  where  the  weaker  parts  of  the 
parictes  of  the  abdomen  give  way.  I  once  thought,  and 
it  is,  I  believe,  the  general  opinion,  that  ruptures  occur 
more  frequently  in  fat  than  in  lean  people ;  but  from  some 
conversation  which  I  have  had  with  persons  whose  line 
of  life  leads  them  to  give  particular  attention  to  this 
disease,  I  am  disposed  to  think  that  this  opinion  is  ill 
founded.  Ruptures  are  found  to  be  as  frequent  in  persons 
who  are  not  corpulent,  as  in  those  who  are.* 

There  is  hardly  any  viscus  which  has  not  at  some  time 
or  other,  been  found  in  the  sack  of  a  rupture,  but  most 
frequently  it  is  either  a  portion  of  the  omentum,  or  of  the 
intestines,  or  of  both.  The  bag  formed  by  the  peritonaeum 
may  be  thrust  out  almost  at  any  part  of  the  belly;  but  this 
happens  most  frequently  at  the  ring  of  the  external  oblique 
muscle,  under  Paupart's  ligament,  and  at  the  navel:  it 
also  sometimes  takes  place  at  other  parts  of  the  abdomen. 
There  is  another  situation  where  a  rupture  has  been 
known  to  happen,  although  very  rarely,  viz.  through  an 
opening  in  the  diaphragm  into  the  thorax.  The  opinion 
which  would  most  obviously  be  formed  about  this  is,  that 
a  portion  of  the  diaphragm  had  burst,  and  a  part  of  the 
intestines  had  protruded  into  the  opening  made  in  the 
diaphragm.  I  am  persuaded,  however,  that  this  opinion 
will  almost  always  be  ill  founded.  It  happens,  sometimes, 
but  very  seldom,  that  children  are  born  with  a  hole  in  the 
diaphragm,  which  is  a  malformation  or  monstrosity  in  this 
part  of  the  body.  When  the  hole  is  large,  a  considerable 


*  The  umbilical  rupture  should  be  considered  as  an  exception  to  this  remark* 
for  it  is  much  more  common  in  fat  people  than  those  of  a  spare  habit. 


105 

portion  of  the  abdominal  viscera  passes  into  the  thorax, 
and  so  impedes  the  functions  of  the  heart  and  lungs,  that 
children  under  these  circumstances  perish  immediately 
after  birth.  When  the  hole  in  the  diaphragm  is  small,  it 
lays  the  foundation  of  the  hernia  or  rupture  which  we  have 
just  described,  and  which  may  be  called,  by  way  of  dis- 
tinction, the  diaphragmatic  hernia.* 

It  is  well  known  that  the  most  usual  situation  of  a  rup- 
ture in  the  male,  is  at  the  ring  of  the  external  oblique  mus- 
cle; and  this  arises  probably  from  the  larger  size  of  that 
opening  in  the  male  than  in*he  female.  The  most  usual 
situation  of  a  rupture  in  the  female  is  known  also  to  be 
either  under  Paupart's  ligament,  or  at  the  navel.  The  rea- 
son of  the  frequency  of  the  first  situation,  is  the  particular 
shape  of  the  pelvis  in  the  female,  by  which  there  is  a  larger 
empty  space  under  Paupart's  ligament,  than  in  the  male, 
so  that  the  viscera  at  that  part  are  less  firmly  supported. 
The  reason  why  the  second  situation  of  a  rupture  occurs 
often  in  the  female,  is,  probably,  frequent  child  bearing. 
During  pregnancy,  at  its  advanced  period,  the  navel  opens, 
or  gives  way,  and  where  pregnancies  have  been  frequent, 
it  probably  never  recovers  its  original  strength, 

The  omentum  is  more  commonly  found  in  the  sack  of 
a  rupture  than  any  of  the  viscera.  This  perhaps  arises  from 
its  being  a  loose  mass,  not  being  tied  down  to  any  particu- 
lar situation,  and  therefore  readily  passes  into  any  cavity 
which  communicates  with  the  abdomen.  When  it  has  once 
fallen  down,  it  has  no  means  of  pulling  itself  out,  like  a 
portion  of  intestine,  which  is  another  reason  why  it  is  so 

A  case  of  this  kind  has  occurred  to  Dr  Clarke,  and  has  been  published  by 
him  in  the  2d  volume  of  the  Medical  and  Chirurgical  Transactions,  p.  118.  He 
has  been  so  obliging1  as  to  give  me  the  preparation  which  illustrates  this  hernia- 

Q 


106 

often  found  in  a  rupture.  When  it  has  remained  long  in 
a  sack,  it  forms  a  pretty  compact  mass,  sometimes  having 
no  connection  with,  but  at  other  times  adhering  to  the  in- 
ner surface  of  the  sack.  There  is  frequently  no  inflamation 
produced  in  the  omentum  while  in  this  situation,  but  oc- 
casionally violent  inftamation  takes  place,  which  may  even 
advance  to  mortification. 

A  portion  of  gut  is  very  often  lodged  in  the  sack  of  a 
rupture,  either  by  itself,  or  along  with  a  portion  of  the 
omentum.  The  portion  of  gut  is  sometimes  very  small 
but  sometimes  it  is  very  considerable.  Very  often  the  func- 
tions of  the  intestines  go  on  properly  in  this  situation,  but 
occasionally  violent  inflamation  is  produced,  interrupting 
their  function,  and  often  terminating  fatally.  This  inflam- 
mation is  produced  by  the  gut  being  strongly  pressed  at 
the  narrowest  part  of  the  sack,  viz.  at  that  part  where  the 
sack  immediately  passes  out  of  the  cavity  of  the  abdomen. 
This  inflamation  exhibits  the  different  appearances,  upon 
dissection,  which  we  have  so  often  related.  The  gut  too, 
is  frequently  found  mortified:  this  is  shewn  by  its  dark 
colour,  by  its  want  of  proper  tenacity,  and  by  the  air 
which  is  formed  within  it.  When  the  inflammation  of  the 
gut  in  a  sack  has  not  been  very  violent,  and  has  termina- 
ted by  resolution,  it  frequently  leaves  adhesions  behind  it7 
connecting  the  gut  with  the  inner  surface  of  the  sack.  It 
is  perhaps  possible  too,  that  adhesions  may  be  formed  by 
long  close  contact,  without  inflammation. 

When  the  sack  of  a  rupture  has  not  been  of  long  stand- 
ing, it  consists  of  a  thin,  firm,  white,  opaque,  membrane ; 
this  is  a  protuded  part  of  the  peritonaeum,  somewhat  thick- 
ened by  pressure.*  When  the  sack  has  been  of  long  stand- 

*  In  some  cases  of  umbilical  hernia,  Dr.  Marshall  has  observed  no  distinct 
appearance  of  peritonaea!  sack.  This  must  have  arisen  from  the  peritonaeum 


107 

ing,  it  is  often  very  thick,  and  evidently  consists  of  a 
number  of  layers.  The  sack  upon  the  inside  has  a  very 
smooth  surface,  and  the  membrane  which  forms  this 
surface  can  be  readily  traced  into  the  peritonaeum,  lining 
the  cavity  of  the  abdomen ;  the  outer  surface  of  the  sack 
is  more  rough  and  coarse  in  its  texture.  The  sack,  where 
it  passes  out  of  the  cavity  of  the  abdomen,  has  frequently 
a  narrow  neck,  or  aperture,  and  is  distended  below  into  a 
bag  of  considerable  size.  At  other  times,  the  communi- 
cation between  the  sack  and  the  cavity  of  the  abdomen, 
is  by  a  larger  opening* 

Hernia  Congenita. 

In  bubonocele  the  sack  is  usually  quite  distinct  from 
the  sack  of  the  tunica  vaginalis  testis.  Sometimes, 
however,  there  is  no  separation  between  them,  and  the 
contents  of  the  rupture  are  immediately  in  contact  with 
the  body  of  the  testicle:  this  kind  of  rupture  is  called  the 
hernia  congenita.  It  was  formerly  supposed  to  arise  from, 
a  portion  of  the  sack  of  the  rupture  and  of  the  tunica 
vaginalis  having  given  way,  so  that  the  contents  of  the 
rupture  fell  into  the  cavity  of  the  tunica  vaginalis  testis, 
and  came  in  contact  with  the  testicle.  Upon  a  little  re- 
flection, it  might  have  been  perceived  that  this  could 
hardly  take  place;  though  the  true  account  of  this  appear- 
ance was  not  known  till  it  was  explained  by  Dr.  Hunter. 
Baron  Haller  discovered,  that  till  about  the  eighth  month 
the  testicles  do  not  descend  into  the  scrotum,  but  are 
situated  in  the  cavity  of  the  abdomen  under  the  kidneys. 
When  they  descend  into  the  scrotum,  the  peritonaeum 

having  burst,  in  consequence  of  distention,  and  its  ruptured  edges  being  lotf: 
by  adhesion  in  the  neighbouring  partSi 


108 

that  covers  them  is  necessarily  drawn  down  along  with 
them  through  the  ring  of  the  external  oblique  muscle;  it 
then  forms  a  bag,  the  upper  extremity  of  which  communi- 
cates with  the  cavity  of  the  abdomen.  Baron  Haller  had 
also  observed,  that  in  infants  a  portion  of  intestine  some- 
times falls  down  into  this  bag  after  the  testicle,  or  along 
with  it,  producing  what  he  called  the  hernia  congenita. 
The  communication  between  the  bag  and  the  abdomen  is 
commonly  closed,  sometimes  a  little  before,  and  some- 
times soon  after  birth.  It  appears,  however,  that  if  it 
be  prevented  from  closing  at  the  usual  time,  it  does  not 
afterwards,  but  remains  open  through  life.  Hence,  if  any 
portion  of  an  intestine,  or  of  the  omentum,  falls  into  the 
elongated  sack  of  the  peritonaeum,  it  must  be  in  contact 
with  the  testicle.  When  Dr.  Hunter  became  acquainted 
with  the  observations  of  Baron  Haller  upon  the  descent  of 
the  testicles,  he  saw  at  once  that  the  species  of  rupture 
sometimes  to  be  met  with  in  adults,  where  a  portion  of 
intestine  or  omentum  is  in  contact  with  the  testicle,  might 
be  easily  explained.  His  explanation  corresponded  with 
that  which  we  have  just  given,  and  has  been  universally 
adopted  by  anatomists  and  surgeons. 

Scirrhus  and  Cancer  of  the  Intestines. 

Scirrhus  is  a  disease  which  takes  place  much  more 
commonly  in  the  great  than  in  the  small  internes,  but 
the  latter  are  occasionally  affected  by  it.  I  have  seen  a 
scirrhous  tumour  and  a  cancerous  ulcer  in  the  duodenum. 
In  the  great  intestines,  at  an  advanced  period  of  life, 
scirrhus  is  not  uncommon :  every  portion  of  this  intestine 
is  not  equally  liable  to  be  affected  by  it,  but  it  is  to  be 
found  much  more  frequently  at  the  sigmoid  flexure  of  the 


109 

colon,  or  in  the  rectum,  than  any  where  else,  which  per- 
haps may  depend  on  the  following  circumstances.  There 
is  certainly  more  of  glandular  structure  in  the  inner  mem- 
brane of  the  great  intestines  towards  its  lower  extremity, 
than  in  any  other  part  of  it,  and  this  sort  of  structure  has 
a  greater  tendency  to  be  affected  with  scirrhus,  than  the 
ordinary  structures  of  the  body :  the  gut  too  is  narrower 
at  the  sigmoid  flexure  than  at  any  other  part,  and  therefore 
will  be  more  liable  to  be  injured  by  the  passage  of  hard 
bodies ;  which,  by  their  irritation,  may  excite  the  disease 
of  scirrhus  in  a  part  that  was  predisposed  to  it. 

The  scirrhus  sometimes  extends  over  a  considerable 
length  of  the  gut,  viz.  several  inches;  but  generally  it  is 
more  circumscribed.  It  exhibits  the  same  appearances  of 
structure  which  were  described  when  speaking  of  scirrhus 
of  the  stomach.  The  peritoneal,  muscular,  and  internal 
coats  are  much  thicker  and  harder  than  in  a  natural  state. 
The  muscular  too  is  subdivided  by  membranous  septa, 
and  the  internal  coat  is  sometimes  formed  into  hard  irregu- 
lar folds.  It  often  happens  that  the  surface  of  the  inner 
membrane  is  ulcerated,  producing  cancer.  Every  vestige 
of  the  natural  structure  is  occasionally  lost,  and  the  gut 
appears  changed  into  a  gristly  substance.  When  scirrhus 
affects  the  gut,  the  passage  at  that  part  is  always  narrowed, 
and  sometimes  so  much  so  as  to  be  almost  entirely  ob- 
structed. The  obliteration,  or  structure,  would  sometimes 
appear  to  be  greater  than  in  proportion  to,  the  thicknesss 
of  the  sides  of  the  diseased  gut :  this  most  probably  de- 
pends upon  the  contraction  of  the  muscular  fibres  of  the 
gut,  which,  although  diseased,  have  not  altogether  lost 
their  natural  action.  Where  the  passage  is  very  much 
obstructed,  the  gut  is  much  enlarged  immediately  above 


110 

the  obstruction,  from  the  accumulation  of  the  contents  in 
that  part  of  the  intestine.  While  this  disease  is  going  on 
in  a  portion  of  the  intestine,  adhesions  are  formed  between 
it  and  the  neighbouring  viscera,  and  the  ulceration  some- 
times spreads  from  the  one  to  the  other. 

The  diseased  Change  of  the  Intestines  in  Dysentery. 

The  inner  membrane  of  the  great  intestines  I  have  seen 
a  good  deal  thickened,  and  formed  into  small  irregular 
tubercles,  some  of  which  were  of  a  white,  and  others  of  a 
yellowish  colour;  the  peritonaea!  and  muscular  coats  were 
also  thicker  and  harder  than  in  a  natural  state,  and  the 
diameter  of  the  intestine  was  a  good  deal  contracted.  In 
some  places  too  the  inner  membrane  appeared  abraded, 
and  the  tubercles  were  sometimes  fissured  upon  the  sur- 
face, so  as  to  resemble  a  little  common  warts.  This  is  not 
a  frequent  appearance  of  disease,  but  it  has  generally  been 
found  to  take  place  in  very  severe  dysenteries,  such  as 
those  which  occasionally  arise  in  camps.  In  the  common 
cases  of  dysentery,  which  take  place  during  the  autumnal 
season  in  this  country,  the  morbid  appearances  just  de- 
scribed are  commonly  not  found ;  at  least  no  instance  of 
it  has  fallen  under  my  observation-  When  such  cases 
prove  fatal,  a  number  of  ulcers  are  discovered  by  examina- 
tion after  death,  in  the  inner  membrane  of  the  great  and 
sometimes  of  the  small  intestines. 

Thickened  Folds  of  the  Inner  Membrane  of  the  great 
Intestines. 

I  have  also  seen  the  internal  membrane  of  the  great 
intestines  formed  into  broad  thick  folds,  in  which  a  con- 
siderable quantity  of  blood  was  accumulated;  these  folds 


Ill 

were  perfectly  independent  of  the  state  of  contraction  in 
the  muscular  coat,  and  were  very  different  in  their  ap- 
pearance from  the  irregular  puckering  which  is  often  seen 
in  the  inner  membrane  of  the  great  intestines.  When 
these  folds  were  examined,  they  were  found  to  consist  of 
an  accumulation  of  cellular  membrane,  with  the  inner 
coat  of  the  gut  reflected  over  it. 

Upon  the  inner  surface  of  the  great  intestine,  about 
two  inches  above  the  anus,  little  processes  sometimes  grow 
from  the  internal  membrane:  they  generally  surround  the 
gut  at  short  distances  from  each  other,  so  as  to  form  a 
sort  of  circle. 

Polypous  Tumours. 

Polypous  tumours  are  occasionally  formed  in  the  great 
intestines,  but  this  morbid  appearance  is  not  of  frequent 
occurrence.  They  take  place  chiefly  in  the  lower  part  of 
the  rectum,  but  they  arc  sometimes  found  as  high  up 
as  the  sigmoid  flexure  of  the  colon.  They  grow  from 
the  inner  surface  of  the  intestine  by  a  narrow  neck  or 
pedicle,  and  fill  up  according  to  their  size  more  or  less  of 
its  cavity.  I  recollect  to  have  met  with  one  instance  of  a 
polypus  nearly  as  large  as  the  fist,  which  grew  in  the 
sigmoid  flexure  of  the  colon,  and  formed  there  a  fatal 
cause  of  obstruction.  When  the  polypus  is  situated  very 
low  down  in  the  rectum,  and  more  especially  if  it  be  not 
large,  it  may  be  removed  by  a  ligature,  and  the  passage  of 
the  intestine  may  become  as  free,  as  before  the  growth  of 
the  polypus. 

A  Milt-like  Tumour  growing  from  the  Mucous  Membrane 
of  the  Intestines. 

Professor   Monro,   junior,   has   described   a  tumour 


growing  from  the  mucous  membrane  of  the  intestines,  of 
a  very  peculiar  kind,  which  he  has  called  the  milt-like 
tumour.  It  is  of  very  rare  occurrence,  and  resembles  a 
good  deal  in  its  consistence  and  appearance  the  milt  of 
many  fishes.  It  grows  by  a  number  of  small  processes 
from  the  mucous  membrane,  and  has  a  remarkable 
offensive  factor.  I  have  never  seen  myself  any  instance  of 
this  tumour,  and  I  do  not  recollect  to  have  heard  it 
mentioned  in  my  communications  with  other  anatomists.* 

Piles. 

Piles  and  fistula?  in  ano,  are  diseases  which  are  ex- 
tremely common,  but  which  hardly  ever  become  an  object 
of  examination  after  death ;  they  have  therefore  not  been 
so  commonly  introduced  into  accounts  of  morbid  appear- 
ances, as  others  which  much  more  rarely  occur.  Piles 
are  soft  tumours  commonly  situated  round  the  verge  of 
the  anus,  sometimes  of  a  regularly  bulbous,  and  some- 
times of  an  irregular  form.  They  are  covered  with  a 
very  tender  skin,  which  partly  consists  of  the  fine  skin 
immediately  round  the  anus  on  the  outside,  and  partly  of 
the  inner  membrane  of  the  gut.  The  tumours  are  gene- 
rally entire,  but  they  have  occasionally  small  openings, 
through  which  a  considerable  quantity  of  blood  is  some- 
times poured;  they  consist  commonly  of  the  veins  round 
the  verge  of  the  anus,  much  enlarged  from  the  accumula- 
tion of  blood.  These  veins  are  branches  of  the  internal 
iliac  vein,  but  they  communicate  largely  with  the  lower 
branches  of  the  mesaraica  minor. 

The  same  sort  of  tumours  are  also  frequently  found 

•  See  Professor  Monro  junior's  Morbid  Anatomy  of  the  Human  Gullet, 
Stomach  and  Intestines. 


113 

within  the  cavity  of  the  rectum,  forming  what  have  been 
called,  the  internal  piles;  and  these  are  occasioned  by  the 
enlargement  of  some  of  the  branches  of  the  mesaraica 
minor.  Piles  are  a  much  more  frequent  disease  in  persons 
who  are  advanced  in  life,  than  in  those  who  are  young. 
They  arise  from  repeated,  and  long  continued  impedi- 
ments to  the  return  of  the  blood  from  the  lower  part  of 
the  rectum,  and  there  has  been  much  more  opportunity 
for  these  impediments  to  act  in  old,  than  in  young 
persons.  They  are  also  more  common  in  women  than 
in  men.  This  may  arise  from  several  causes:  the  uterus 
during  pregnancy  must  occasion  a  great  impediment  to 
the  return  of  the  blood  from  the  rectum ;  this  is  so  much 
the  case,  that  women  who  have  been  frequently  pregnant 
seldom  escape  piles.  Women  too  are  more  apt  to  allow 
of  an  accumulation  of  the  proper  contents  of  the  rectum, 
than  men,  which  will  produce  some  impediment  to  the 
return  of  the  blood  from  this  part. 

Fistula  in  Ano. 

Fistulas  in  ano  are  narrow  canals  at  the  lower  end  of  the 
rectum,  and  are  distinguished  by  the  following  circum- 
stances: they  have  callous  edges,  a  smooth  internal  surface, 
and  possess  the  power  of  secreting  pus.*  A  disease  of 
this  sort  may  consist  of  one  canal,  opening  by  a  very  small 
aperture  externally,  at  the  side  of  the  anus;  or  this  canal 
may  be  divided  into  several  branches.  The  canal,  be- 
sides  opening  externally,  has  very  commonly  a  small 
opening  into  the  gut  itself :  and  sometimes  there  is  a  small 
opening  into  the  gut,  without  there  being  any  externally 

*  Mr.  Hunter  has  observed,  in  his  lectures  on  Surgery,  that  fistulas  have  a 
smooth  internal  surface,  like  a  secreting  surface,  as,  for  instance, 
P 


114 

on  the  side  of  the  anus.     It  is  much  more 
however,  to  find  only  an  external  opening  of  the  canal;  or, 
to  find  both  an  external  opening,  and  another  into  the  gut. 

The  Rectum  terminating  in  a  Cul-de-sac. 

It  is  a  species  of  monstrous  formation  not  very  un- 
common, that  the  rectum  does  not  terminate  in  the  anus, 
but  in  a  cul-de-sac,  without  reaching  the  external  surface. 
Sometimes  the  extremity  of  the  gut  lies  near  the  external 
surface,  but  more  commonly  it  is  at  some  distance  from 
it.  In  these  cases  there  is  usually  the  appearance  of  an 
anus,  but  the  opening  is  more  contracted  than  in  the 
natural  structure.  It  seldom  happens  that  this  malforma- 
tion can  be  effectually  remedied  by  a  chirurgical  operation. 
The  opening  which  is  made  into  the  extremity  of  the  gut 
has  generally  such  a  disposition  to  close,  that  the  benefit 
which  might  naturally  be  expected  from  an  operation  is 
frustrated.  A  few  cases  however  have  occurred  in  which 
the  operation  has  been  successful. 

The  Rectum  terminating  in  the  Bladder. 

I  have  also  seen  the  rectum  terminate  in  the  bladder^ 
from  an  original  error  in  the  formation,  so  that  there  was 
no  other  external  opening  to  the  rectum  than  by  the 
urethra:  this  was  in  a  child  at  birth:  the  malformation  was 
of  such  a  kind,  as  neither  to  admit  of  a  remedy  by  art,  nor 
to  allow  of  life  being  continued. 

The  rectum  has  also  been  known  to  terminate  in  the 
vagina,  from  a  defect  in  the  original  formation;  but  this  is 
very  uncommon. 


115 


Worms. 

Worms  are  formed  in  the  intestines  of  man,  as  well  as 
of  many  other  classes  of  animals;  but  not  so  frequently  in 
the  former  as  in  the  latter.  In  most  quadrupeds  and  fishes 
it  is  extremely  common  to  find  a  number  of  worms  upon 
opening  their  intestines. 

The  worms  which  are  found  in  the  human  subject,  may 
be  reduced  to  three  general  classes,  viz.  the  lumbricus 
teres;  taenia;  and  ascaris. 

Lumbricus  Teres. 

The  lumbricus  teres,  or  round  worm,  is  much  more 
commonly  found  in  the  intestines  of  children,  than  in  those 
of  persons  full  grown,  or  advanced  in  life,  it  is  very  usually 
met  with  in  the  first,  but  rarely  in  the  two  last.  The  lum- 
bricus teres  is  well  known  to  differ  from  the  common 
earth  worm,  but  many  practitioners  in  this  country  have 
made  little  inquiry  into  the  circumstances  upon  which  this 
difference  depends.  The  two  species  of  worms,  if  attentive- 
ly examined,  will  be  found  to  differ  a  good  deal  from  each 
other  in  their  external  appearance.  The  lumbricus  teres 
is  more  pointed  at  both  extremities,  than  the  common 
earth  worm.  The  mouth  of  the  lumbricus  teres  consists 
of  three  rounded  projections,  with  an  intermediate  cavity; 
the  mouth  of  the  earth  worm  consists  of  a  small  longitu- 
dinal fissure,  situated  on  the  under  surface  of  a  small 
rounded  head,  Upon  the  under  surface  too  of  this  worm 
there  is  a  large  semi-lunar  fold  of  skin,  into  which  the 
head  retreats,  or  out  of  which  it  is  elongated,  but  this  is 
entirely  wanting  in  the  lumbricus  teres.  The  anus  of  the 
lumbricus  teres  opens  upon  the  under  surface  of  the  worm? 


116 

a  little  way  from  its  posterior  extremity,  by  a  transverse, 
curved  fissure;  the  anus  of  the  earth  worm  opens  by  an 
oval  aperture  at  the  very  extremity  of  the  worm.  The 
outer  covering  or  skin  in  the  lumbricus  teres  is  less  fleshy, 
and  less  strongly  marked  by  transverse  rugae,  than  in  the 
earth  worm.  In  the  latter  there  is  often  to  be  seen  a  broad 
yellowish  band,  surrounding  the  body  of  the  wormjbutin 
the  lumbricus  teres,  this  is  entirely  wanting,  on  each  side 
of  the  lumbricus  teres  there  is  a  longitudinal  line  very 
well  marked;  in  the  earth  worm  there  are  three  longitudi- 
nal lines  upon  the  upper  half  of  its  surface,  but  these  are 
so  faintly  marked,  as  to  be  hardly  observable.  The  lum- 
bricus teres  has  nothing  corresponding  to  feet;  whereas  the 
earth  worm  has  on  its  under  surface,  but  more  strongly 
marked  towards  its  posterior  extremity,  a  quadruple  row 
of  processes  on  each  side,  very  sensible  both  to  the  eye, 
and  the  finger,  which  manifestly  serve  the  purposes  of 
feet  in  the  locomotion  of  the  animal. 

The  internal  structure  of  these  two  species  of  worms  is 
also  extremely  different.  In  the  lumbricus  teres,  there  is 
an  intestinal  canal,  nearly  uniform  and  smooth  in  its  ap- 
pearance, which  passes  from  one  extremity  of  the  worm 
to  the  other.  Near  the  head  of  this  worm,  the  canal  is 
narrower  than  it  is  any  where  else,  and  somewhat  distinct 
in  its  limits :  this  may  be  considered  as  the  oesophagus. 
In  the  earth  worm,  there  is  a  large  and  complex  stomach, 
consisting  of  two  cavities;  and  the  intestinal  canal  in  the 
latter  is  likewise  larger,  and  more  formed  into  sacculi,  than 
In  the  former.  The  parts  subservient  to  generation  in 
these  two  species  of  worms  differ  very  much  from  each 
other  5  in  the  lumbricus  teres  there  is  a  distinction  of  sex. 
the  parts  of  generation  being  different  in  the  male  and  in 


117 

the  female;  in  the  common  earth  worm  the  organs  of  gen- 
eration are  the  same  in  each  individual,  as  this  worm  is 
hermaphrodite.  The  appearance  too  of  the  organs  of  gen- 
eration is  extremely  different  at  first  sight  in  the  one  species 
of  animal  and  in  the  other.  There  is  an  oval  mass  situated 
at  the  anterior  extremity  of  the  earth  worm  resembling  a 
good  deal  the  medullary  matter  of  the  brain ;  in  the  lum- 
bricus  teres  this  substance  is  wanting.*  Those  are  the 
principal  differences  between  the  one  species  of  animal  and 
the  other,  which  are  obvious  upon  a  very  moderate  atten- 
tion to  each.  Many  other  differences  would,  doubtless, 
be  found  by  a  person  who  might  choose  to  prosecute  their 
anatomy  minutely. 

Tgnia, 

The  Tzenia  which  is  most  commonly  found  in  the 
human  intestines,  is  of  two  kinds,  viz.  the  taenia  solium, 
and  the  tsenia  lata. 

Taenia  So  Hum. 

This  taenia  is  frequently  bred  in  the  intestines  of  the 
inhabitants  of  Germany,  and  occasionally,  but  rarely,  in 
those  of  the  inhabitants  of  Great  Britain.  It  consists  of  a 
great  many  distinct  portions,  which  are  connected  together 
so  as  to  put  on  a  jointed  appearance ;  these  joints  are 
commonly  of  a  very  white  colour,  but  occasionally  brown- 
ish, which  depends  on  a  fluid  of  this  colour  that  is  found 
in  their  vessels.  The  worm  usually  is  very  long,  extending 
often  many  yards,  and  seldom  passes  entire  from  the 

*  What  this  substance  is  I  do  not  know,  and  I  have  only  mentioned  its  resem- 
blance to  the  medullary  matter  of  the  brain,  in  order  to  give  a  clearer  descrip- 
tion of  it. 


118 

bowels.    This  circumstance  has  prevented  the  extremities 
of  the  tasnia  from  being  often  seen. 

The  head  of  this  tsenia  is  somewhat  of  a  square  form, 
with  a  narrowed  projection  forwards ;  in  the  middle  of  this 
projecting  part,  there  is  a  distinct  circular  aperture,  around 
the  edge  of  which  grow  curved  sharp  processes,  Near 
the  angles  of  the  square  edge  of  the  head,  are  situated  four 
round  projecting  apertures,  at  equal  distances  from  each 
other:  this  head  is  placed  upon  a  narrow  jointed  portion 
of  the  worm,  of  considerable  length,  and  which  gradually 
spreads  itself  into  the  broader  joints,  of  which  the  body  of 
the  worm  is  composed. 

The  body  of  the  tsenia  consists  of  thin,  flat,  pretty  long 
joints,  on  one  edge  of  which  there  is  a  projection,  with  a 
very  obvious  aperture.  In  the  same  worm  some  of  these 
joints  appear  considerably  longer  than  others,  which 
probably  depends  on  one  joint  being  contracted  while 
another  is  relaxed.  The  apertures  which  we  have  just 
mentioned  are  generally  placed  on  the  opposite  edges  of 
the  contiguous  joints;  but  this  is  not  uniformly  the  case; 
they  are  sometimes  placed  on  the  same  edges  of  two,  or 
even  several  contiguous  joints.  When  these  joints  are 
examined  attentively,  there  are  frequently  seen,  in  each  of 
them,  vessels  filled  with  a  brownish  fluid,  and  disposed  in 
an  arborescent  form.  Around  the  edges  of  each  joint, 
there  is  also  a  distinct  serpentine  canal.*  The  last  joint 
of  a  taenial  resembles  very  much  a  common  joint  rounded 
off  its  extremity  ,  and  without  any  aperture. 

*  This,  as  well  as  the  vessels  disposed  in  an  arborescent  form,  is  very 
distictly  seen  injected  in  some  preperations  which  have  been  made,  and  given 
*Q  me  by  an  ingenious  Surgeon,  Mr.  Carlisle. 


119 


Ttenia  Lata. 

The  tsenia  lata  is  bred  very  commonly  in  the  intestines 
of  the  inhabitants  of  Switzerland,  but  very  rarely  in  those 
of  the  inhabitants  of  Great  Britain.  The  joints  of  which 
it  is  composed  are  short  and  broad,  and  the  aperture  is  not 
upon  the  edge  of  each  joint,  as  in  the  solium,  but  in  the 
middle  of  its  flattened  surface.  Round  these  apertures  are 
short  radiated  vessels.  The  head  is  of  an  oval  shape,  and 
so  small  that  its  minute  structure  is  not  visible  to  the  naked 
eye.  Its  tail  terminates  in  two  narrow  processes,  one  of 
which  is  longer  than  the  other. 

Other  tsenia  have  occasionally  been  found  in  the  human 
intestines,  but  they  occur  very  rarely,  and  have  not  fallen 
under  my  own  observation. 

Ascaris. 

The  ascaris  is  a  very  small  worm,  which  is  often  found 
at  the  lower  end  of  the  rectum  in  children,  and  even  more 
frequently  in  adults  than  is  commonly  imagined.  It  is 
white  in  its  colour,  and  about  half  an  inch  in  length;  at  the 
extremity  where  its  head  is  placed,  it  is  a  little  narrowed, 
and  at  the  other  extremity  it  terminates  in  a  long,  very 
fine,  transparent  process.  These  worms  are  more  or  less 
surrounded  with  mucus  which  is  secreted  in  increased 
quantity  by  the  glands  in  the  inner  membrane  of  the  rectum, 
from  the  irritation  occasioned  by  the  worms. 

Trichuris 

This  worm  has  been  occasionally  found  in  the  great 
intestines  of  man,  and  more  especially  the  coecum.  it  re- 
sembles a  good  deal  the  arscaris,  but  is  considerably  larger- 


126 

and  has  a  very  long  transparent  tail.  To  their  heads  ib 
attached  a  process  or  horn,  which  they  can  protrude  or 
retract. 

There  is  nothing  in  the  economy  of  animals  more 
obscure  than  the  origin  of  intestinal  worms;  were  they 
found  to  live  out  of  the  bodies  of  living  animals,  one 
might  readily  suppose  that  their  ovula  were  taken  into  the 
body  along  with  the  food  and  drink,  and  there  gradually 
evolved  into  animals.  This,  however,  is  not  the  case; 
the\  do  not  seem  capable  of  living  for  any  length  of  time 
in  any  situation,  except  within  a  living  animal  body,  which 
appears  to  be  the  proper  place  for  their  growth  and 
residence.  We  might  therefore  be  led  to  another 
supposition,  viz.  that  intestinal  worms  are  really  formed 
from  the  matter  contained  in  the  intestines,  which  previously 
had  no  regular  organization;  but  this  idea  is  widely 
different  from  all  analogy  in  the  production  of  animals, 
where  there  has  been  any  satisfactory  opportunity  of 
examining  this  production.  The  origin,  therefore,  of  such 
animals  is  a  subject  of  much  obscurity,  and  probably  will 
not  soon  have  any  satisfactory  light  thrown  upon  it. 

Air  accumulated  in  the  Intestines. 

It  is  not  unusual  to  find  air  accumulated  in  the  intestinal 
canal,  in  greater  or  less  quantity;  this  air  is  sometimes, 
but  not  constantly,  accompanied  with  a  slight  inflamma- 
tion of  the  peritonseum.  In  such  cases  the  blood  vessels, 
creeping  upon  the  intestines,  are  sometimes  filled  with  air, 
but  frequently  they  are  without  it.  Air  is  often  let  loose 
into  the  intestines  after  death  by  putrefaction;  but  that 
which  we  wish  particularly  to  consider  here,  has  been 
formed  during  life. 


There  are  only  two  ways  in  which  we  can  well  con- 
ceive  air  to  be  formed  in  the  intestines:  the  one  is,  some 
new  arrangement  in  the  contents  of  the  intestines,  by 
which  air  is  extricated :  the  other  is,  the  formation  of  air 
in  the  blood  vessels  of  the  intestines,  and  which  air  is 
afterwards  poured  out  by  the  extremities  of  the  exhalent 
arteries  into  the  cavity  of  the  intestines.  That  the  blood 
vessels  of  an  animal  body  have  th,is  power  there  can  be  no 
doubt;  and  I  own  I  am  inclined  to  think  that  this  is  a 
mode  by  which  air  is  not  unfrequently  accumulated  in 
the  intestines.  This  air  probably  differs  somewhat  at 
different  times:  in  several  trials  which  I  have  made,  it 
never  shewed  signs  of  containing  any  proportion  of  in- 
flammable air,  but  always  a  very  sensible  proportion  of 
fixed  air.  It  requires,  however,  to  be  examined  by  some 
.person  well  acquainted  with  chemical  experiments,  ia 
order  that  its  ingredients  may  be  exactly  ascertained. 

Bony  Matter  formed  in  the  Intestines* 

These  are  the  most  common  appearances  of  diseased, 
or  preternatural  structure  in  the  intestines:  but  I  have 
likewise  had  an  opportunity  of  observing  others,  which 
are  of  rarer  occurrence.  In  one  or  two  instances,  I  have 
seen  a  sort  of  bony  matter  formed  upon  the  surface  of  the 
inner  membrane  of  the  gut :  I  have  even  seen  an  adhesion 
between  two  portions  of  intestine  converted  into  bone.  It 
would  appear,  that  almost  every  part  of  the  body  is  occa- 
sionally subject  to  this  process.  It  may  not  improperly 
be  considered,  as  a  natural  process  misplaced.  An  adhesion 
being  once  formed,  has  the  same  power  (as  far  as  we  know) 
of  running  into  different  processes,  as  the  cellular  mem- 
brane which  makes  a  part  of  the  original  structure.  It 

Q 


122 

may  therefore  form  bone,  as  readily  as  cellular  membrane^ 
or  some  other  membranes  of  the  body,  which  have  a  re- 
semblance to  the  membrane  of  adhesions,  as  the  pleura, 
and  the  peritonaeum. 

Projecting  Ring  formed  in  the  Cavity  of  the  Jejunum. 

I  have  seen  one  of  the  valvulas  conniventes  much  larger 
than  usual,  and  passing  round  on  the  inside  of  the  jejunum, 
like  a  broad  ring.  The  canal  of  the  gut  was  necessarily 
much  narrowed  at  this  ring,  but  no  mischief  had  arisen 
from  it.  This  malformation,  however,  might  have  laid 
the  foundation  of  fatal  mischief.  Some  substance  too 
large  to  pass,  might  have  rested  on  the  ring,  and  produced 
there  inflammation,  ulceration,  and  ultimately  death. 

Concretions  in  the  Intestines. 

Concretions  have  occasionally  been  found  in  some  part 
of  the  cavity  o£  the  intestinal  canal,  especially  in  the  great 
intestine,  but  I  have  not  met  with  any  instance  of  this 
kind,  in  the  very  numerous  examinations  of  dead  bodies, 
which  I  have  made.  It  may  therefore  be  considered  as 
a  rare  occurrence.  A  great  many  specimens  of  these 
concretions  have  been  collected  by  Professor  Monro,  and 
a  clear  account  of  them  has  been  given  by  his  son.  They 
are  lamellated  in  their  texture,  of  a  colour  between  yellow- 
ish brown  and  chesnut  brown,  contain  generally  a  nucleus 
in  their  centre,  and  are  often  of  a  large  size.  They  con- 
sist chiefly  of  phosphate  of  lime,  a  ^natter  resembling  a 
good  deal  vegetable  extractive,  and  a  peculiar  substance, 
which  is  of  small  specific  gravity,  and  has  an  appearance  a 
good  deal  like  that  of  cork.* 

*  See  Dr.  Monro  junior's.  Morbid  Anatomy  of  tlie  Human  Gullet,  Stomach  an£ 
lujtestines. 


123 


Small-fox  Pustules  said  to  be  in  the  Intestines. 

Small-pox  pustules  have  been  said  to  be  sometimes 
found  in  the  intestines  of  persons  who  had  died  from  this 
disease,*  How  far  this  may  have  occasionally  taken  place, 
I  will  not  pretend  to  say,  but  late  dissections,  upon  the 
best  authority,  have  not  confirmed  this  fact. 

Diseased  Appearances  of  the  Mesentery. — Mesentery 
inflamed. 

The  mesentery  is  often  found  in  a  state  of  inflammation; 
although  I  believe  this  hardly  ever  takes  place  unless  when 
the  peritonaeum  generally  is  inflamed.  When  the  mesentery 
is  inflamed,  it  becomes  much  thicker,  and  more  massy, 
than  in  its  natural  state ;  the  large  blood  vessels  which 
pass  between  its  laminae  and  the  absorbent  glands,  are  also 
very  much  obscured.  These  different  appearances  de- 
pend upon  the  quantity  of  the  coagulable  lymph  which  is 
poured  out,  during  the  inflammatory  action.  The  peri- 
tonaeum which  forms  the  laminae  of  the  mesentery  is 
crowded  with  small  vessels,  and  is  covered  more  or  less 
with  a  layer  of  the  coagulable  lymph.  A  small  quantity  of 
pus  is  sometimes  found  on  the  surface  of  the  inflamed 
mesentery,  and  even  abscesses  have  been  observed  between 
its  laminae;  but  this  last  appearance  is  very  rare. 

It  very  seldom  happens,  that  the  mesentery  is  found  to 
be  gangrenous,  unless  different  portions  of  the  intestinal 
canal  be  in  the  same  state.  When  the  intestines  are 
mortified,  portions  of  the  mesentery  are  sometimes  found 
in  the  same  condition.  The  appearances  exhibited  in 

*  Yid.  Lieutaud,  Tom.  I,  p.  37L 


124 

mortification  are  the  same  when  it  affects  the  mesentery, 
as  in  any  other  part,  and  they  have  been  already  described. 

Me  sent  eric  Glands  scrofulous. 

The  absorbent  glands  of  the  mesentery  are  frequently- 
found  to  be  scrofulous,  and  this  is  more  apt  to  take  place 
in  children,  than  in  persons  of  a  more  advanced  age. 
When  affected  with  this  disease,  the  glands  exhibit 
different  appearances,  according  to  its  progress :  they  arc 
enlarged  in  their  size,  and  are  often  somewhat  softer  to  the 
touch,  than  in  a  natural  state.  When  cut  into,  they  some- 
times shew  very  much  the  natural  structure ;  but  rhore 
frequently  they  are  changed,  in  part,  into  a  white,  soft, 
curdly  matter,  and  this  is  not  uncommonly  mixed  with 
pus. 

Mesenteric  Glands  cancerous. 

When  a  portion  of  the  intestinal  canal  becomes  cancer- 
ous, some  of  the  absorbent  glands  in  the  mesentery 
generally  become  affected  with  the  same  disease:  this 
is  in  consequence  of  the  matter  of  cancer  being  con- 
veyed to  those  glands  by  those  absorbent  vessels.  The 
glands  become  enlarged  in  size,  and  are  changed  into 
hard  masses  exhibiting  a  scirrhous,  or  a  cancerous  structure. 

Mesenteric  Glands  earthy  or  bony. 

The  absorbent  glands  of  the  mesentery  are  sometimes 
filled  with  an  earthy,  or  bony  matter;  but  this  is  to  be 
considered  as  a  rare  occurrence.*  The  absorbent  glands 
at  the  root  of  the  lungs,  are  more  liable  to  be  affected 
with  this  disease, 

*  Vid.  Med.  Transactions,  Vol.  I.  p.  361. 


125 


Hydatids  have  also  been  occasionally  found  adhering 
to  the  mesentery. 


Tumours,  likewise,  consisting  of  a  fatty  matter,  have 
been  seen  attached  to  the  mesentery ;  but  these  I  believe 
to  be  very  uncommon. 


SYMPTOMS. 

Inflammation  of  the  intestines  is  characterized  by  the 
following  symptoms,  viz.  an  acute  pain  in  the  abdomen, 
vomiting,  obstinate  costiveness,  symptomatic  fever,  with 
a  frequent,  small  and  hard  pulse.  The  pulse,  however, 
is  sometimes  less  affected  than  might  have  been  supposed, 
from  the  violence  of  the  inflammation. 


The  symptoms  attending  intus-susceptio  are  similar 
to  those  which  belong  to  inflammation  of  the  intestines, 
and  indeed  this  disease  is  not  unfrequently -accompanied 
with  inflammation.  It  is  however  more  likely  to  prove 
fatal  than  simple  inflammation  of  the  bowels,  as  it  does 
not  admit  of  any  substantial  benefit  from  medicine. 


126 

When  there  is  a  rupture  without  any  strangulation  of 
the  intestine,  the  following  symptoms  take  place,  viz.  a 
pale  swelling  at  the  part  affected,  a  slight  pain  occasion- 
ally felt  in  the  swelling  itself,  and  spread  somewhat  over 
the  region  of  the  belly,  the  swelling  pushed  out  by 
coughing,  a  disappearance  of  the  swelling  upon  pressure, 
or  upon  the  person  continuing  for  a  considerable  length  of 
time  in  a  horizontal  posture.  When  a  rupture  is  large 
and  of  long  standing,  it  will  often  be  incapable  of  being 
reduced  by  pressure,  even  when  there  is  no  strangulation. 

When  strangulation  takes  place,  the  same  symptoms 
arise  which  belong  to  inflammation  of  the  bowels,  for 
the  strangulation  produces  inflammation.  These  consist 
of  a  pain  in  the  swelling,  which  is  diffused  over  the  abdo- 
men, sickness,  vomiting,  obstinate  costiveness,  heat  com- 
monly a  frequent,  small,  and  a  hard  pulse :  and  towards 
the  fatal  conclusion  of  the  disease,  there  is  hickup,  with 
a  foetid  yellow  matter  thrown  out  by  the  mouth.  The 
sickness  I  have  heard  described,  as  being  infinitely  more 
distressing  than  the  ordinary  sickness  of  a  deranged 
stomach ;  the  pulse  is  'sometimes,  in  such  a  case,  not 
increased  in  frequency  beyond  the  standard  of  health;  and 
yet  the  inflammation  of  the  bowel  has  been  discovered 
afterwards  by  the  operation  to  be  very  great.  This  is  an 
important  practical  observation,  because  it  shews  that  the 
degree  of  inflammation  is  not  to  be  judged  of  from  the 
pulse,  and  teaches  that  the  operation  should  not  be  delayed, 
after  the  proper  efforts  for  reducing  the  rupture  have  failed, 
because  the  pulse  may  happen  to  be  little  or  not  at  all 
accelerated. 


127 


When  a  considerable  quantity  of  pus  is  formed  in  cbn 
sequence  of  an  ulcer  in  the  bowels,  it  is  known  by  the  pus 
being  evacuated  by  stool,  which  is  frequently  a  little  tinged 
with  blood.  Severe  pains  are  frequently  felt  in  the  bowels, 
and  there  is  a  propensity  to  go  often  to  stool.  The  pulse 
is  often  at  first  not  more  frequent  than  in  health,  but  is 
afterwards  a  good  deal  accelerated.  The  appetite  for  food 
is  commonly  not  much  impaired. 


When  the  great  intestine  is  attacked  with  scirrhus,  the 
disease  has  commonly  made  some  progress,  before  it  is 
much  attended  to  by  the  patient.  At  first  there  is  but 
little  pain  in  the  part  affected,  and  the  patient  only  ob- 
serves that  he  is  costive,  or  that  the  stools  pass  with  some 
difficulty.  When  the  disease  is  more  advanced,  a  consid- 
erable pain  is  felt,  more  especially  in  passing  a  stool,  and 
there  are  occasional  sympathetic  pains  about  the  os  sacrum 
and  hips.  When  the  stools  are  examined,  they  are  com- 
monly found  to  be  narrow,  to  be  more  or  less  flattened, 
often  in  some  degree  serpentine  in  their  shape,  and  they 
are  sometimes  besmeared  with  mucus,  pus,  and  blood. 
The  pulse  at  the  beginning  of  this  disease  is  natural,  but 
towards  its  close  becomes  accelerated.  In  advanced  stages 
of  the  disease,  the  countenance  is  sallow,  the  strength  is 
much  impaired,  the  body  is  much  emaciated,  and  the 
constitution  at  length  altogether  sinks. 


128 


"iVhcn  an  ulcer  of  the  rectum  has  spread  to  the  bladder, 
it  is  known  by  air  often  escaping  along  with  urine,  and 
from  the  urine  being  sometimes  more  or  less  mixed  with 
faeces.  Severe  pain  is  occasionally  felt  in  the  lower  part 
of  the  belly.  The  pulse  is  sometimes  accelerated,  and 
sometimes  not  more  frequent  than  in  health. 

In  dysentery,  griping  pains  are  felt  in  the  abdomen, 
which  often  arise  to  a  considerable  degree  of  severity. 
The  bowels  are  irritated  to  frequent  evacuation,  and  gene- 
rally  discharge  mucus  tinged  with  blood,  but  sometimes 
white  lumps,  membranous  films,  pus,  and  at. intervals 
scybala.  Tenesmus  accompanies  the  evacuation  of  the 
bowels ;  and  there  is  more  or  less  of  fever  connected  with 
this  complaint. 


When  a  polypus  is  large  and  situated  so  high  up  in  the 
great  bowel,  as  to  be  beyond  the  reach  of  an  operation,  it 
must  form  at  length  >a  fatal  cause  of  obstruction. 

The  difficulty  in  passing  the  fasces  must  become  greater 
and  greater,  till  the  obstruction  is  complete.  Patients  are 
generally  sensible  of  the  obstruction  being  at  a  particular 
part  of  the  bowel,  and  often  sufier  much  from  the  accu- 
mulation of  fasces  and  of  wind,  above  the  polypus,  and 
from  colicky  pains.  The  stomach  too  is  occasionally 
affected  with  sickness  and  vomiting.  When  the  polypus 
is  very  low  down  in  the  rectum,  and  not  very  large,  it 
forms  a  partial  obstruction  to  the  passage  of  the  faeces, 
and  can  in  general  be  removed  by  a  ligature. 


129 


The  symptoms  attending  piles  are  swellings  at  the  verge 
of  the  anus,  or  in  the  rectum  immediately  above  it,  pain  felt 
at  the  anus  during  the  passage  of  the  faeces,  frequently  art. 
evacuation  of  blood,  and  occasional  feelings  of  irritation  in 
the  parts  affected*  This  disease  is  often  preceded  by  other 
affections,  such  as  giddiness  of  the  head,  difficulty  of  breath- 
ing, colicky  pains,  and  pains  in  the  loins. 


The  symptoms  which  attend  the  round  worm  of  the 
intestines  are  a  swelled  belly,  emaciated  extremities,  an 
offensive  breath,  and  a  deranged  appetite.  The  appetite 
is  often  greater  than  in  health,  but  sometimes  it  is  much 
less.  The  stools  are  slimy;  and  the  patient  frequently" 
picks  his  nose,  and  during  sleep  grinds  his  teeth. 


Persons  afflicted  with  the  taenia,  complain  of  a  gnawing 
uneasy  feeling  in  the  region  of  the  stomach,  which  is  re- 
moved or  diminished  by  eating.  Their  appetite  is  com- 
monly somewhat  voracious,  but  occasionally  it  is  less  than 
natural.  They  have  commonly  an  itching  at  the  nose, 
often  nausea,  colicky  pains,  and  sometimes  giddiness. 
Some  have  a  cough,  and  others  occasional  convulsions. 


When  ascarides  are  lodged  in  the  rectum,  there  is  an 
uneasy  feeling  there,  and  a  violent  itehing  at  the  anus. 
R 


130 

There  is  also  a  sense  of  heat  in  the  parts,  with  occasional 
tenesmus  and  mucus  stools.  The  mucus  is  sometimes 
mixed  with  blood,  and  along  with  it  some  living  ascarides 
are  often  discharged.* 


The  symptoms  attending  alvine  concretions  are  not 
likely  to  be  always  very  distinctly  marked.  There  is 
sometimes  nausea  and  vomiting,  and  often  violent  attacks 
of  pain  in  some  part  of  the  belly.  There  is  frequently 
costiveness,  and  sometimes  watery,  mucous  and  bloody 
stools.  When  the  disease  has  been  of  long  standing,  the 
patient  is  generally  much  emaciated,  and  then  the  concre- 
tion can  be  felt  as  a  ball,  on  pressing  with  the  fingers  some 
part  of  the  bowels.  This  forms  the  most  discriminative 
symptom  of  the  disease.  When  the  ball  has  got  low  down 
in  the  rectum,  it  will  often,  by  compressing  the  bladder, 
produce  an  obstruction  to  the  evacuation  af  the  urine.  In 
this  situation  the  concretion  can  sometimes  be  removed 
by  a  forceps,  and  sometimes  will  pass  away  without  any 
artificial  assistance. 


When  air  is  accumulated  in  a  moderate  quantity  in  the 
bowels,  it  is  known  to  exist  by  some  fulness  of  the  abdomen, 
and  by  the  air  shifting  frequently  its  situation.  This  is 
sometimes  attended  with  a  kind  of  gurgling  noise,  and 
forms  swellings  in  particular  parts  of  the  belly.  A  quan- 
tity of  air  is  sometimes  expelled  by  the  mouth  and  the 
rectum.  '  There  is  generally  at  the  same  time  costiveness, 
and  occasional  colicky  pains. 

*  See  Med.  Trans,  of  the  college  Vol.  I.  p.  46. 


131 

When  air  is  accumulated  in  very  large  quantity,  then, 
it  forms  a  very  serious  disease  called  tympanitis.  Of 
this  I  have  seen  a  few  instances.  The  belly  is  ex- 
tremely swelled,  with  a  very  tense  feeling,  and  there  is  a 
quick  reaction  of  the  parts  after  removing  the  pressure  of 
the  fingers  from  the  belly,  exactly  similar  to  what  takes 
place  in  a  common  ox's  bladder,  distended  with  air.  When 
the  belly  in  tympanitis  is  struck  with  the  fingers,  there  is 
exactly  the  same  sound  as  when  a  bladder  is  "truck  in  the 
same  way,  that  is  distended  with  air,  but  this  sound  never 
takes  place  upon  striking  with  the  fingers  the  belly  in 
ascites.  There  is  no  sense  of  fluctuation  in  tympanitis, 
but  in  ascites  this  is  commonly  distinct.  There  is  often 
difficulty  of  breathing,  which  is  produced  by  the  accumu- 
lation of  the  air  pushing  up  the  diaphragm,  and  impeding 
its  free  motion.  There  are  severe  colicky  pains,  and 
quantities  of  air  are  frequently  expelled  both  upwards  and 
downwards  with  a  loud  noise.  The  bowels  are  costive, 
and  there  is  a  difficulty  in  making  water,  which  is  proba- 
bly occasioned  by  the  accumulation  of  air  in  the  rectum. 


The  symptoms  of  an  inflamed  mesentery  cannot  be 
separated  from  those  which  belong  to  inflammation  of  the 
peritonaeum  generally;  and  these  symptoms  have  been 
already  described. 


The  symptoms  which  attend  the  enlargement  of  the 
mesenteric  glands  from  scrofula  correspond  very  much? 


132 

in  the  most  striking  circumstances,  with  the  symptoms 
which  are  produced  by  the  common  round  worm  of  the 
intestines.  In  both  diseases  there  is  a  tumid  belly,  and 
emaciated  extremities.  They  are  chiefly  to  be  distin- 
guished by  worms  not  being  discovered  in  the  one  disease, 
notwithstanding  the  use  of  strong  purgatives,  while  they 
pass  off  from  the  bowels  in  the  other.  The  startings,  the 
itching  of  the  nose,  and  the  grinding  of  the  teeth,  may 
perhaps  also  form  some  ground  of  distinction  between  the 
two  diseases:  they  occur  very  commonly  in  worms,  but 
I  believe  rarely  where  the  glands  of  the  mesentery  are 
scrofulous.  Some  discrimination  likewise  between  the 
two  diseases,  may  sometimes  be  derived  from  examining 
strictly  into  the  nature  of  the  constitution.  If  decided 
marks  of  scrofula  shew  themselves  in  an  external  part  of 
the  body,  they  will  lead  a  practitioner  more  satisfactorily 
to  the  opinion,  that  the  mesenteric  glands  are  also  affected 
with  the  same  disease. 


CHAPTER  IX. 


DISEASED   APPEARANCES  OF   THE  LIVEH. 

Inflammation  of  the  Membrane  of  the  Liver. 

THE  external  membrane  of  the  liver  is  not  uncom- 
monly found  in  a  state  of  inflammation. 

This  may  take  place  when  the  peritonaeum  generally 
over  the  cavity  of  the  abdomen  is  inflamed,  or  the  in- 
flammation  may  be  confined  to  the  membrane  of  the  liver 
itself.  When  it  is  confined  to  the  membrane  of  the  liver, 
it  is  not  frequently  extended  over  the  whole  of  it,  but  more 
commonly  takes  place  in  that  portion  of  it  which  covers 
the  anterior,  or  convex  part  of  the  liver.  I  have  also  seen 
inflammation,  or  at  least  its  effects,  not  unfrequently  on 
that  side  of  the  liver,  which  is  in  contact  with  the  stomach 
and  the  duodenum. 

When  inflammation  takes  place  in  the  membrane  of 
the  liver,  it  exhibits  exactly  the  same  appearances,  which 
have  been  described  when  speaking  of  the  inflammation 
of  the  peritonaeum,  of  which  it  is  a  part.  It  is  crowded 
with  a  great  number  of  very  minute  vessels,  which  contain 
florid  blood,  and  is  thicker  than  in  its  natural  state.  There 
is  also  formed  upon  its  surface,  a  layer  of  coagulablc 
lymph:  this  layer  is  thicker  on  some  occasions  than 
others,  and  often  glues  the  liver,  more  or  less  completely 
to  the  neighbouring  parts.  Some  quantity  of  serous  fluid 
is  at  the  same  time  poured  out. 


134 


Adhesions. 

It  is  more  common  to  see  adhesions  formed,  which  are 
the  consequence  of  a  previous  inflammation  in  the  mem- 
brane of  the  liver,  than  to  see  the  membrane  in  an  actual 
state  of  inflammation.  These  adhesions  are  formed  from 
the  coagulable  lymph  of  the  blood  which  undergoes  a 
gradual  progress  of  change,  as  we  have  formerly  described. 
They  consist  very  commonly  of  a  fine  transparent  mem- 
brane, which  joins  the  surface  of  the  liver  to  the  neigh- 
bouring parts.  This  junction  may  either  be  general, 
over  one  extended  surface  of  the  liver,  or  it  may  consist 
of -a  number  of  processes  of  adhesion:  the  adhesion  is 
sometimes  by  a  membrane  of  considerable  length;  and 
sometimes  the  adhesion  is  very  close,  the  surface  of  the 
liver  being  immediately  applied  to  the  neighbouring  parts. 
The  surface  of  the  liver,  where  these  adhesions  are  most 
commonly  found,  is  the  anterior,  by  which  it  is  joined  to 
the  peritonaeum  lining  the  muscles  at  the  upper  part  of 
the  cavity  of  the  abdomen. 

When  an  abscess  is  formed  in  the  substance  of  the  liver, 
and  points  externally,  these  adhesions  are  of  great  use  in 
preventing  the  pus  from  escaping  into  the  general  cavity 
of  the  abdomen.  Adhesions  are  also  frequently  found 
connecting  the  posterior  surface  of  the  liver  to  the  stomach, 
and  the  duodenum;  and  these  may  also  be  useful  in 
abscesses  of  the  liver,  near  its  posterior  surface,  by  pre- 
venting the  matter  from  passing  into  the  general  cavity  of 
the  abdomen,  and  conducting  it  either  into  the  stomach, 
or  the  upper  part  of  the  intestinal  canal. 

Coats  of  the  Liver  converted  into  Cartilage. 
A  part  of  the  coats  of  the  liver  is  sometimes  changed 


135 

into  cartilage.  Of  this  I  have  seen  a  few  instances;  but 
it  occurs  much  more  rarely  in  the  liver  than  in  the  spleen. 
The  cartilage  is  smooth  and  thin,  and  soft  in  its  texture. 

Inflammation  of  the  Substance  of  the  Liver. 

It  does  not  often  happen,  in  this  country,  that  the 
substance  of  the  liver  is  found  in  an  actual  state  of  in- 
flammation. Where  its  membrane-  is  inflamed,  the  sub- 
stance is  sometimes  inflamed  which  lies  immediately  under 
it;  but  it  rarely  happens  that  the  general  mass  of  the  liver 
is  inflamed.  In  warmer  countries,  the  substance  of  the 
liver  is  much  more  liable  to  inflammation  than  in  Great 
Britain.  When  the  liver  is  generally  inflamed  through  its 
substance,  it  is  a  good  deal  enlarged  in  its  size,  and  of  a 
purple  colour.*  It  is  also  harder  to  the  touch,  than  in  its 
healthy  state.  Its  outer  membrane  is  sometimes  affected 
by  the  inflammation,  and  sometimes  it  is  not.  It  is 
attended  occasionally  with  a  jaundiced  colour  of  skin, 
arising  from  the  bile  not  getting  readily  into  the  ductus 
communis  choledochus  on  account  of  the  pressure  of  the 
inflamed  liver  on  the  pori  biliarii.  When  this  inflammation 
has  continued  for  some  time,  abscesses  are  formed,  and 
then  the  active  state  of  the  inflammation  very  much  sub- 
sides.  These  abscesses  are  sometimes  of  a  large  size,  so 
as  even  to  contain  some  pints  of  pus.  Sometimes  the 
whole  of  the  liver  is  almost  converted  into  a  bag  containing 
pus.  When  inflammations  of  the  liver  have  been  of  con- 
siderable  standing,  they  are  not  uncommonly  attended 

*  May  not  the  purple  colour  arise  from  the  accumulation  of  blood  in  the 
branches  of  the  vena  portarum  ? 

As  this  vein  performs  the  office  of  an  artery  in  the  liver,  is  it  not  probable, 
that  its  small  branches  take  on  the,  same  actions  as  the  small  branches  of  an 
artery  during  inflammation  ? 


136 

With  ascites,  and  the  water  is  of  a  yellow,  or  green  colour, 
being  tinged  by  the  bile. 

The  liver  has  sometimes  been  said  to  have  been  in  a 
state  of  mortification.*  This  however  occurs  very  rarely, 
and  has  never  fallen  under  my  own  observation. 

Common  Tubercle  of  the  Liver. 

One  of  the  most  common  diseases  in  the  liver  (and 
perhaps  the  most  common,  except  the  adhesions,  which 
we  have  lately  described),  is  the  formation  of  tubercles 
in  its  substance.  This  disease  is  hardly  ever  met  with  in 
very  young  persons,  but  frequently  takes  place  in  persons 
of  middle  or  advanced  age :  it  is  likewise  more  common 
in  men  than  women.  It  is  more  apt  to  occur  in  those  who 
have  been  accustomed  to  drink  spirituous  liquors,  but 
it  will  likewise  frequently  take  place  in  persons  who  have 
not  indulged  in  this  bad  habit,  and  who  have  lived  with 
general  temperance. 

The  tubercles  which  are  formed  in  this  disease  occupy 
generally  the  whole  mass  of  the  liver,  are  placed  very  near 
each  other,  and  are  of  a  rounded  shape.  They  give  an 
appearance  every  where  of  irregularity  to  its  surface. 
When  cut  into,  they  are  found  to  consist  of  a  brownish 
or  yellowish  white  solid  matter.  They  are  sometimes  of 
a  very  small  size,  so  as  not  to  be  larger  than  the  heads  of 
large  pins ;  but  most  frequently  they  are  as  large  as  small 
hazel  nuts,  and  many  of  them  are  sometimes  larger. 
When  the  liver  is  thus  tuberculated,  it  feels  much  harder 
to  the  touch  than  natural,  and  not  uncommonly  its  lower 
edge  is  bent  a  little  forward.  Its  size,  however,  is  gene- 

*  Vid.  Morgagni  Epist.  XXXI V.  Art.  25. 
Also  see  Portal's  Anatomie  Medicale,  Tom.  V.  p.  306f 


137 

rally  not  larger  than  in  a  healthy  state,  and  I  think  it  is 
often  smaller.  If  a  section  of  the  liver  be  made  in  this 
state,  its  vessels  seem  to  have  a  smaller  diameter  than  they 
have  naturally.  It  very  frequently  happens  that  in  this 
state  the  liver  is  of  a  yellow  colour,  arising  from  the  bile 
accumulated  in  its  substance;  and  there  is  also  water  in 
the  cavity  of  the  abdomen,  which  is  yellow  from  the 
mixture  of  bile.  The  gall-bladder  is  generally  much 
contracted,  and  of  a  white  colour,  from  its  being  empty. 
The  bile,  from  the  pressure  of  the  hard  liver  upon  the  pori 
biliarii,  does  not  reach  the  ductus  hepaticus,  and  therefore 
cannot  pass  into  the  gall-bladder.  The  colour  of  the  skin 
in  such  cases  is  jaundiced,  and  in  general  it  remains  per- 
manently so,  as  it  depends  on  a  state  of  liver  scarcely  liable 
to  change.  This  is  the  common  appearance  of  what  is 
generally  called  a  scirrhous  liver:  but  it  bears  only  a  remote 
resemblance  to  scirrhus,  as  It  shews  itself  in  other  parts  of 
the  body.  I  should  therefore  be  disposed  to  consider  it 
as  a  peculiar  disease  affecting  this  viscus.  When  the 
jaundice  has  continued  for  a  long  time,  as  is  commonly 
the  case  in  this  diseased  state  of  the  liver,  the  blood  in  all 
the  blood  vessels  of  the  tjody  is  either  found  not  to  be 
coagulated  at  all  after  death,  or  to  be  coagulated  very 
loosely.  Whether  this  be  the  constant  state  of  the  blood 
in  such  cases  or  not,  I  am  not  able  to  determine.  Most 
probably  however  it  is,  as  it  is  reasonable  to  think,  that  it 
depends  upon  the  chemical  influence  of  a  mixture  of  a 
certain  proportion  of  the  but  with  the  blood. 

Large  white  Tubercle  of  the  Liver. 

Hard  white  masses  are  sometimes  formed  in  the  liven 
They  are  often  as  large  as  a  chesnut;  but  I  have  seen 
S 


138 

"them  both  a  good  deal  larger  and  smaller  than  this  size. 
They  are  to  be  found  near  the  surface  of  the  liver  in  greater 
number,  than  near  the  middle  of  its  substance:  two  or 
three  frequently  lie  contiguous  to  each  other,  with  a  con- 
siderable portion  of  the  liver,  in  a  healthy  state,  interposed 
between  them  and  a  cluster  of  similar  tubercles.  They 
consist  of  a  firm,  opaque,  white  substance,  and  are  gene- 
rally somewhat  depressed,  or  hollow,  upon  their  outer 
surface.  The  liver  in  this  disease  is  frequently  a  good 
deal  enlarged  beyond  its  natural  size. 

These  tubercles  appear  to  be  first  formed  round  the 
blood  vessels  of  the  liver,  as  is  seen  in  making  sections  of 
a  liver  in  this  state.  While  the  liver  is  under  such  cir- 
cumstances of  disease,  there  is  sometimes  water  in  the 
cavity  of  the  abdomen,  and  at  other  times  none ;  the  liver 
is  sometimes  tinged  in  its  colour,  from  the  accumulation 
of  bile,  and  sometimes  the  colour  of  its  substance  between 
the  tubercles  is  perfectly  natural. 

The  kind  of  tubercle  which  we  have  now  descibed,  is 
much  more  rare  than  the  other,  and  resembles  more  the 
ordinary  appearance  of  scirrhus  in  other  parts  of  the  body. 
In  one  or  two  instances,  however,  I  have  observed  a  thick 
sort  of  pus  lodged  in  this  species  of  tubercle  resembling 
very  much  the  pus  from  a  scrofulous  sore ;  and  therefore 
I  am  rather  disposed  to  think  that  this  tubercle  may  be  of 
a  scrofulous  nature,  but  no  satisfactory  opinion  can  be 
formed  upon  this  single  circumstance. 

S(ft  brown  Tubercles  of  the  Liver. 

I  have  also  seen  in  the  liver  a  number  of  soft  tumours, 
about  the  size  of  a  walnut:  they  were  principally  situated 
at  the  surface  of  the  liver,  and  consisted  of  a  smooth,  soft, 


139 

brownish  matter.  This  is  a  very  rare  appearance  of 
disease :  such  tumours  would  by  many  be  considered  as 
scrofulous,  but  there  is  no  good  evidence  in  support  of 
this  opinion ;  and  there  is  certainly  no  resemblance  between 
this  sort  of  tumour  and  either  a  scrofulous  tubercle  of  the 
lungs,  or  a  scrofulous  absorbent  gland.  About  its  real 
nature  nothing  satisfactory  is  ascertained. 

Scrofulous  Tubercles  of  the  Liver 

Tubercles  are  occasionally  found  in  the  liver,  which 
bear  a  strong  resemblance  to  the  tubercles  of  the  lungs  ; 
but  this  is  a  very  rare  appearance  of  disease.  They  have 
the  same  size,  the  same  structure,  and  the  same  feeling  to 
the  touch,  but  are  a  little  browner  in  their  colour.  In 
the  only  instance  which  I  have  seen  of  this  disease,  the 
tubercles  were  generally  dispersed  through  the  substance 
of  the  liver  at  pretty  regular  distances,  but  did  not  render 
the  surface  of  the  liver  irregular,  as  in  the  common  sort  of 
tubercle.  From  their  appearance  and  structure  I  am 
strongly  disposed  to  consider  them  as  scrofulous. 

Liver  flaccid,  with  reddish  tumours. 

1  have  likewise  seen  the  liver  much  more  flaccid  in  its 
substance  than  is  natural,  with  reddish  soft  tumours,  of 
considerable  size,  interspersed  through  it,  which  contained 
a  thick  sort  of  pus.  I  am  not  acquainted  with  the  real 
nature  of  these  tumours,  but  I  think  it  proper  to  mention 
that  they  were  found  in  a  person  whose  general  constitution 
had  strong  marks  of  scrofula,  and  in  whom  also  were 
found  many  scrofulous  absorbent  glands  on  examining 
the  body.  They  probably  may  have  belonged  to  thai 


140 

species  of  disense,  which  is  called  the  fungus  haematodes.* 

Liver  very  soft  in  its  Substance. 

The  liver  is  not  unusually  found  much  more  flaccid  in 
its  substance  than  natural  without  any  other  appearance 
of  disease.  It  feels  upon  such  occasions  nearly  as  soft  as 
the  spleen,  and  is  commonly  of  a  leaden  colour.  This 
change  must  arise  from  a  process  which  takes  place 
through  its  whole  substance,  and  seems  to  be  what  Mr. 
Hunter  has  called  the  interstitial  absorption.  By  this 
process  is  meant,  the  absorbents  removing  insensibly  the 
very  minute  parts  out  of  the  general  mass  of  any  structure 
in  an  animal  body  without  ulceration.  This  state  of  the 
liver  is  very  rarely,  if  ever,  found  in  a  very  young  person, 
and  is  most  common  in  persons  who  are  advanced  in  life. 

Liver  very  hard  in  its  Substance. 

There  is  a  very  contrary  state  of  the  liver,  not  at  all 
unusual,  viz.  where  it  is  much  harder  than  natural,  and 
when  cut  into,  exhibits  no  peculiar  structure.  Upon  the 
surface  of  these  livers,  there  is  not  uncommonly  a  thready 
appearance  of  membrane,  disposed  somewhat  in  a  radiated 
form,  and  the  lower  edge  is  bent  a  little  forwards.  This 
I  believe  to  be  the  first  step  in  the  progress  towards  the 
formation  of  the  common  tuberculated  liver.  I  have  some- 
times  seen  very  small  tubercles  formed  upon  a  part  of  the 
surface  of  such  a  liver,  which  were  exactly  of  the  common 
sort.  From  this  appearance,  it  is  probable,  that  additional 
matter  is  deposited  in  the  interstices,  through  the  general 

*  Such  of  my  readers  as  may  wish  to  examine  these  various  tubercles  more 
minutely,  will  find  an  excellent  account  given  of  them  by  Dr.  Fane  in  his 
Fasciculi. 


141 

mass  of  the  liver,  rendering  it  much  harder,  and  that  this 
matter,  together,  perhaps,  with  part  of  the  ordinary  struc- 
ture of  the  liver,  is  converted  into  tubercles.  This  har- 
dened state  of  the  liver  is  sometimes  accompanied  with  a 
beginning  ascites,  and  sometimes  is  without  it. 

Hydatids. 

There  is  no  gland  in  the  human  body  in  which  hydatids 
are  so  frequently  found  as  the  liver,  except  the  kidneys.* 
Hydatids  of  the  liver  are  usually  found  in  a  cyst,  which  is 
frequently  of  considerable  size,  and  is  formed  of  very  firm 
materials,  so  as  to  give  to  the  touch  almost  the  feeling  of 
cartilage.  This  cyst,  when  cut  into,  is  obviously  lamina- 
ted, and  is  much  thicker  in  one  liver"  than  another.  In 
some  livers,  it  is  not  thicker  than  a  shilling,  and  in  others, 
it  is  near  a  quarter  of  an  inch  in  thickness.  The  laminae 
which  compose  it  are  formed  of  a  white  matter,  and  on 
the  inside  there  is  lining  of  a  pulpy  substance,  like  the 
coagulable  lymph.  The  cavity  of  the  cyst  I  have  seen,  in 
one  instance,  subdivided  by  a  partition  of  this  pulpy  sub- 
stance. In  a  cyst  may  be  found  one  hydatid,  or  a  greater 
number  of  them.  They  lie  loose  in  the  cavity,  swimming 
in  a  fluid;  or  some  of  them  are  attached  to  the  side  of  the 
cyst.  They  consist  each  of  a  round  bag,  which  is  com- 
posed of  a  white,  semi  opaque,  pulpy  matter,  and  contains 
a  fluid  capable  of  coagulation.  Although  the  common 
colour  of  hydatids  be  white,  yet  I  have  occasionally  seen 
some  of  a  light  amber  colour.  The  bag  of  the  hydatid 


*  Although  the  hydatids  of  the  liver,  and  the  kidney,  have  got  the  same 
name,  yet  frequently  they  differ  from  each  other.  Hydatids,  however,  occasion- 
ally occur  in  the  kidneys  which  are  precisely  of  the  same  kind  with  those  of 
the  liver. 


142 

consists  of  two  laminae,  and  possesses  a  good  deal  of  con- 
tractile  power.  In  one  hydatid  this  coat,  or  bag,  is  much 
thicker  and  more  opaque  than  in  another,  and  even  in  the 
same  hydatid  different  parts  of  it  will  often  differ  in  thick- 
ness. On  the  inside  of  an  hydatid,  smaller  ones  are 
sometimes  found,  which  are  commonly  not  larger  than 
the  heads  of  pins,  but  sometimes  they  are  even  larger  in 
their  size  than  a  gooseberry.  These  are  attached  to  the 
larger  hydatid,  either  at  scattered  irregular  distances,  or  so 
as  to  form  small  clusters;  and  they  are  also  found  floating 
loose  in  the  liquor  of  the  larger  hydatids.  Hydatids  of 
the  liver  are  often  found  unconnected  with  each  other; 
but  sometimes  they  have  been  said  to  inclose  each  other 
in  a  series,  like  pill-boxes.  The  most  common  situation 
of  hydatids  of  the  liver,  is  in  its  substance,  and  inclosed 
in  a  cyst;  but  they  are  occasionally  attached  to  the  outer 
surface  of  the  liver,  hanging  from  it,  and  occupying  more 
or  less  of  the  general  cavity  of  the  abdomen. 

The  origin  and  real  nature  of  these  hydatids  are  not  fully 
ascertained;  it  is  extremely  probable,  however,  that  they 
are  a  sort  of  imperfect  animalcules.  There  is  no  doubt 
that  the  hydatids  in  the  livers  of  sheep  are  animalcules  : 
they  have  been  often  seen  to  move  when  taken  out  of  the 
liver  and  put  into  warm  water;  and  they  retain  this  power 
of  motion,  for  a  good  many  hours  after  a  sheep  has  been 
killed.  The  analogy  is  very  strong  between  hydatids  in 
the  liver  of  sheep,  and  in  that  of  the  human  subject.  In 
both  they  are  contained  in  strong  cysts,  and  in  both  they 
consist  of  the  same  white  pulpy  matter.  There  is  un- 
doubtedly some  difference  between  them  in  simplicity  of 
organization;  the  hydatid  in  the  human  liver  being  a 
simple  uniform  bag,  and  the  hydatid  in  that  of  the  sheep 


143 

having  a  neck  and  mouth  appended  to  the  bag.  This 
difference  need,  however,  be  no  real  objection  to  the 
opinion  above  stated.  Life  may  be  attached  to  the  most 
simple  form  of  organization.  In  proof  of  this,  hydatids 
have  been  found  in  the  brains  of  sheep,  resembling  almost 
exactly  those  in  the  human  liver,  which  have  been  seen 
to  move,  and  therefore  are  certainly  known  to  be  animal- 
cules. The  hydatids  of  the  human  liver  indeed,  have  not, 
as  far  as  I  know,  been  found  to  move  when  taken  out  of 
the  body  and  put  into  warm  water;  had  this  ever  happened, 
no  uncertainty  would  remain.  •  It  is  not  difficult  to  see 
a  good  reason  why  there  will  hardly  occur  any  proper 
opportunity  of  making  this  experiment.  Hydatids  are 
not  very  often  found  in  the  liver:  and  the  body  is  allowed 
to  remain  for  so  long  a  time  after  death  before  it  is  ex- 
amined, that  the  hydatids  must  have  lost  their  living- 
principle,  even  if  they  were  animalcules.  The  probability 
of  their  being  animalcules;  however,  is  very  strong ;  and 
it  appears  even  more  difficult  to  account  for  their  produc- 
tion according  to  the  common  theory  of  generation,  than 
for  that  of  intestinal  worms.  We  do  not  get  rid  of  the 
difficulty  by  asserting  that  hydatids  in  the  human  liver  are 
not  living  animals,  because  in  sheep  they  are  certainly 
such,  where  the  difficulty  of  accounting  for  their  produc- 
tion is  precisely  the  same.  If  any  person  should  wish  to 
consider  hydatids  more  minutely,  he  will  find  an  excellent 
account  of  them  published  by  Dr.  John  Hunter  in  the 
"first  volume  of  the  Medical  and  Chirurgical  Transactions.* 

*  See  Medical  and  Chirurgical  Transactions,  Vol.  I.  p.  34- 


144 


Cysts  in  the  Liver  containing  an  earthy  Matter. 

Cysts  are  occasionally  formed  in  the  liver,  containing 
an  earthy  matter.  The  cysts  are  composed  of  a  kind  of 
cartilaginous  substance  mixed  with  bone.  The  earthy 
substance  contained  in  the  cyst  is  soft,  smooth,  and  of  a 
brownish  white  colour.  It  is  mixed  with  soft  films  re- 
sembling a  good  deal  in  their  appearance  the  coats  of  an 
hydatid. 

Rupture  of  the  Liver- 

The  liver .  is  more  liable  to  be  ruptured  by  external 
violence  than  any  other  gland  of  the  body,  which  probably 
arises  from  two  causes:   the  one  is,  that  in  thin  persons 
the  liver,  more  especially  when  large,  lies  near  the  surface 
of  the  body,  and  therefore  may  be  readily  affected  by  a 
strong   external  pressure.     The  other  is,  that  the   liver 
consists  of  a  structure,  the  part's  of  which  are  more  easily 
separated   from   each  other  by   pressure,  than   those  of 
almost  any  other  organ  or  structure  in  the  body.     Thus, 
if  the  thumb   or  the  finger  be  pressed  against  the  liver 
with  agoo  d  deal  of  force,  the  liver  gives  way  much  in  the 
same  manner  as  a  rotten  pear  would  do,  although  not  so 
readily.     In  this  trial  the  effect  does  not  depend  upon  the 
liver  being  softened  by  putrefaction,  because  it  will  take 
place  in  the  liver  of  a  person  immediately  after  death.     It 
depends  upon  the  peculiar  structure  of  the  liver,  and  there- 
fore may  take  place  in  the  liver  of  a  person  who  is  alive, 
as  well  as  of  one  who  is  dead.     If  the  same  degree  of 
pressure  be  applied  to  a  muscle,  or  many  glands  of  the 
body,  they  are  not  ruptured,  but  recover  the  v  selves  after 
the  pressure  has  been  removed.     When  ruptures  have 


145 

taken  place  in  the  liver,  they  have  happened  from  some 
strong  pressure  applied  to  the  upper  part  of  the  abdomen; 
as  for  instance,  from  the  wheel  of  a  carriage  passing  over 
that  part  of  the  body.  Little  pain  has  been  felt  from  such 
an  injury;  which  is  a  proof  among  many  others  of  the 
liver  not  possessing  much  sensibility;  and  some  of  the 
persons  to  whom  this  accident  has  happened  continued  to 
live  after  it  for  several  days. 

Worms  said  to  be  in  the  Liver. 

Worms*  have  been  said  to  be  found  in  cysts  of  the 
liver,  as  well  as  in  the  biliary  ducts.  Instances  of  this 
sort  are  extremely  rare,  and  have  not  come  under  my 
own  observation. 


SYMPTOMS. 

When  the  coats  of  the  liver  are  inflamed,  more  especi- 
ally upon  its  convex  surface,  the  symptoms  correspond 
a  good  deal  with  those  of  pleurisy,  in  which  the  inflam- 
mation has  attacked  the  lower  part  of  the  pleura  upon  the 
right  side.  There  is  acute  pain  in  the  part  affected, 
difficulty  of  breathing,  cough,  and  symptomatic  fever. 
The  two  affections  ifiay  however  be  in  general  distinguished 
from  each  other  by  the  following  circumstances.  Where 
the  coats  of  the  liver  are  inflamed  the  pain  will  be  less  in- 
creased upon  deep  inspiration  than  where  the  pleura  at 


*  Vid,  Ueutaud,  Tom.  I.  p.  194, 

T 


the  lower  part  of  the  right  side  of  the  chest  is  inflamed* 
In  inflammation  of  the  coats  of  the  liver  there  will  be  a 
considerable  increase  of  pain  upon  pressure  immediately 
under  the  margin  of  the  ribs,  on  the  right  side,  which  will 
not  take  place  in  inflammation  of  the  pleura. 


1  am  not  acquainted  with  any  symptoms  which  attend 
adhesions  of  the  liver  to  the  neighbouring  parts. 


When  the  substance  of  the  liver  is  inflamed,  there  is  an 
obtuse  pain  in  the  right  hypochondrium,  and  a  pain  is 
often  felt  at  the  top  of  the  right  shoulder.  The  patient 
can  lie  most  easily  on  the  side  affected.  There  is  more 
or  less  of  symptomatic  fever,  sometimes  a  dry  cough, 
sometimes  hickup,  sometimes  vomiting,  and  occasionally 
a  yellow  colour  of  the  skin  and  eyes.  Inflammation  of 
the  substance  of  the  liver  sometimes  takes  place  so  very 
slowly,  that  it  is  hardly  attended  with  any  pain,  and  the 
constitution  is  not  at  all  or  very  little  affected  with  symp- 
toms of  fever.  On  such  occasions  an  inflammation  of  the 
liver  is  not  suspected;  till  an  abscess  has  actually  been 
formed,  and  begins  to  make  its  progress  outwards. 


I  know  of  no  peculiar  symptoms  by  which  the  liver  can 
be  ascertained,  in  the  living  body,  to  be  studded  with 
tubercles.  When,  however,  there  is  pain  or  an  uneasy 


147 

feeling  in  the  region  of  the  liver,  together  with  a  jaundiced 
colour  of  the  skin,  which  continues  permanent,  and  water 
is  at  the  same  time  accumulated  in  the  cavity  of  the 
abdomen;  there  remains  little  doubt  of  the  liver  being 
tuberculated.  When  the  parietes  of  the  abdomen  are  thin, 
and  water  is  accumulated  in  small  quantity  in  that  cavity, 
the  tubercles  upon  the  anterior  surface  and  the  lower  edge 
of  the  liver  can  sometimes  be  distinctly  felt  by  the  fingers, 
upon  an  attentive  examination. 


The  symptoms  which  belong  to  the  large  white  tubercle 
t)f  the  liver,  I  cannot  distinguish  from  those  of  the  com- 
mon tubercle.  Sometimes,  however,  when  the  person  is 
thin  and  the  tubercles  are  near  the  lower  edge  of  the  liver, 
they  can  be  distinguished  by  an  external  examination. 
I  believe  that  the  large  white  tubercle  is  not  so  often 
attended  with  jaundice  and  ascites  as  the  other. 

The  symptoms  which  belong  to  the  other  tubercles  of 
the  liver,  are  unknown  to  me.  It  is  probable  that  there 
are  none  which  are  discriminative. 


When  the  liver  is  becoming  hard  in  its  substance,  the 
exact  state  of  it  cannot  be  determined  in  the  living  body, 
unless  the  person  be  so  thin  that  the  liver  can  be  distinctly 
felt  upon  examination.  This,  however,  will  frequently 
be  very  difficult,  and  on  many  occasions  impossible; 
because  the  liver,  when  hard,  is  commonly  not  increased 
in  its  size,  and  the  parietes  of  the  abdomen  are  of  con- 


148 

siderable  thickness.  If  there  be  some  sense  of  uneasiness 
in  the  region  of  the  liver,  along  with  a  sallow  countenance, 
this  disease  may  be  suspected.  It  has  sometimes  happened, 
however,  that  the  liver  has  been  discovered  to  be  hard, 
upon  an  examination  after  death,  when  no  symptoms  had 
been  observed  during  life,  which  led  to  an  opinion  of  this 
disease  having  taken  place. 


There  are  no  symptoms  which  characterize,  particularly, 
the  formation  of  hydatids  in  the  liver,  and  this  disease  can 
only  be  guessed  at  in  the  living  body.  It  appears  from 
the  history  of  some  cases  of  this  kind,  that  a  pain  is  felt 
in  the  right  hypochondrium;  but  this  may  arise  from 
many  other  causes, 

In  two  cases  which  have  come  to  my  knowledge,  the 
symptoms  were  similar  to  those  which  attend  an  attack  of 
gall-stones.  There  was  a  violent  spasmodic  pain  near  the 
pit  of  the  stomach,  frequent  vomiting,  and  jaundice,  with 
a  pulse  not  accelerated.  These  attacks  occurred  frequently 
in  both  cases  after  considerable  intervals  of  tolerably  good 
health. 

When  hydatids  are  confined  within  the  substance  of 
the  liver,  I  do  not  see  how  it  is  possible  that  their  existence 
should  be  ascertained ;  but  when  they  are  formed  on  the 
outer  surface  of  the  liver,  near  its  lower  edge,  their 
existence  may  in  some  degree  be  ascertained  by  examina- 
tion, more  especially  if  the  person  be  thin.  When, 
however,  the  parietes  of  the  abdomen  are  thick,  and  the 
hydatids,  or  their  cysts  are  not  distinct,  but  lie  in  contact 
with  each  other,  making  an  irregular  tumour,  it  will  hardly 


149 

be  possible  to  form  an  accurate  opinion  by  an  examina- 
tion. If  the  tumour  be  formed  gradually,  and  the  general 
health  be  little  affected,  it  is  probable  that  it  consists  of 
hydatids.  An  accurate  attention  to  the  feeling,  which 
the  tumour  yields  upon  pressure,  or  upon  striking  it 
gently  with  the  hand,  may  also  assist  in  forming  a  probable 
conjecture  about  its  nature.  Where  the  tumour  consists 
of  hydatids  it  will  generally  feel  to  a  certain  degree  soft; 
and  if  the  hydatids  should  be  very  large,  there  may  be 
an  obscure  sense  of  fluctuation  upon  striking  the  tumour 
with  one  hand,  while  the  other  is  applied  to  the  opposite 
side  of  it.  If  moreover,  the  tumour  should  occupy  a 
great  part  of  the  cavity  of  the  abdomen,  and  can  be 
clearly  traced  from  the  liver,  as  the  source  of  its  growth, 
there  can  be  but  little  doubt  of  the  existence  of  hydatids, 
under  these  circumstances. 


150 


.CHAPTER  X. 


DISEASED   APPEARANCES  IN   THE   GALL-BLADDER, 

Inflammation  of  its  Coats 

THE  coats  of  the  gall-bladder  are  very  rarely  inflamed, 
without  inflammation  of  the  membrane  which  covers  the 
posterior  surface  of  the  liver.  When  inflammation  attacks 
this  membrane,  it  naturally  spreads  over  the  outer  coat  of 
the  gall-bladder,  which  is  a  continuation  of  it,  and  may 
affect  the  other  coats  of  the  gall-bladder,  if  it  should /have 
arisen  to  a  violent  degree.  Inflammation,  however,  of  the 
outer  coat  of  the  gall-bladder  will  not  commonly  be 
attended  with  inflammation  of  the  others,  because  it  is  not 
closely  applied  to  them,  there  being  interposed  a  consid- 
erable quantity  of  cellular  membrane.  The  appearances 
of  inflammation  in  the  coats  of  the  gall-bladder,  are  similar 
to  what  take  place  in  inflammation  of  the  stomach  or  in- 
testines. These  have  been  already  fully  described,  and 
need  not  be  repeated. 

Adhesions. 

It  is  a  very  common  appearance,  upon  dissection,  to 
find  the  gall- bladder. connected  by  adhesions,  either  to  the 
small  end  of  the  stomach,  or  to  the  beginning  of  the 
duodenum.  These  are  the  consequence  of  a  previous 
inflammation  in  the  outer  coat  of  the  gall-bladder,  and 
resemble  exactly  the  adhesions  which  we  have  already 
described. 


151 


Ulcers  in  the  gall-Bladder. 

It  is  rare  that  inflammation  of  the  gall-bladder  advances 
to  ulceration :  the  accumulation  of  gall-stones  in  it,  as  far 
as  I  have  observed,  rarely  produces  this  effect.*  Ulcera- 
tion of  the  gall-bladder,  however,  occasionally  takes  place, 
and  I  believe  almost  always  begins  in  the  inner  membrane. 
Of  this  I  have  known  two  cases.  In  the  one  case,  several 
ulcers  were  found  in  the  inner  membrane  of  the  gall- 
bladder, while  the  other  coats  were  not  affected;  and  in 
the  other  there  was  one  ulcer,  which  had  destroyed  a 
part  of  all  the  coats. 

Coats  of  the  Gall-bladder  thickened^  and  hard  Tubercles 
formed  in  them. 

I  have  only  had  an  opportunity  once  of  observing  this 
change  in  the  gall-bladder.  Its  coats  were  above  a  quarter 
of  an  inch  thick,  and  were  studded  with  tubercles  of  a 
considerable  size,  and  very  firm  in  their  texture.  The 
liver  to  which  this  gall-bladder  belonged  was  affected  with 
the  same  disease. 

Coats  of  the  Gall-bladder  bony. 

I  have  likewise  seen  the  coats  of  the  gall-bladder  very 
much  thickened,  and  converted  in  many  parts  into  a  sort 
of  bony  substance ;  but  this  is  to  Ije  considered  as  a  very 
rare  appearance  of  disease. 

*  I  have  myself  only  seen  one  instance  of  inflammation  and  ulceration  of 
the  gall-bladder  produced  by  gall-stones.  Dr.  Soemmerring,  however,  has 
seen  a  good  many  instances  of  ulcers  in  the  inner  surface  of  the  gall-bladder, 
from  tjhe  irritation  of  gall-stones. 


152 


Diseased  state  of  the  Biliary  Ducts. — Their  Dilatation 

The  most  common  diseased  appearance  of  the  biliary 
ducts  is  their  dilatation.  The  ductus  hepaticus,  ductus 
cysticus,  and  ductus  communis  choledochus,  are  some- 
times, dilated  to  an  almost  incredible  size.  I  have  seen 
the  ductus  hepaticus  and  choledochus  so  much  dilated  as 
to  be  nearly  an  inch  in  the  transverse  diameter.  These 
dilatations  of  the  biliary  ducts  take  place  in  consequence  of 
the  passage  of  gall-stones  and  it  is  astonishing  how  large 
gall-stones;  sometimes  are,  which  have  been  known  to 
pass  into  the  duodenum.  This  ought  to  afford  a  strong 
ground  of  comfort  to  persons  who  are  labouring  under  so 
distressing  a  complaint. 

Obliteration  of  the  Biliary  Ducts. 

An  obliteration  of  any  of  the  biliary  ducts  happens  very 
rarely,  but  instances  of  this  disease  have  been  discovered, 
and  they  may  be  traced  to  the  following  causes.  One 
cause  is  a  violent  inflammation,  which  has  taken  place  in 
the  inner  surface  of  some  of  the  biliary  ducts,  and  has 
terminated  in  an  adhesion  of  its  sides.  This  may  be 
supposed  to  arise  most  commonly  from  the  irritation  of  a 
rough  gall-stone,  in  its  passage  toward-  the  duodenum. 
A  similar  adhesion  has  been  known  to  take  place  in  other 
canals  of  the  body,  inconsequence  of  violent  inflammation 
there,  as,  for  instance,  in  the  vagina.  Another  cause, 
which  may  act  upon  the  lower  extremity  of  the  ductus 
communis  choledochus,  obliterating  its  cavity  at  that  part, 
is  a  violent  inflammation  of  the  duodenum  at  the  entrance 
of  the  duct;  the  extremity  of  the  duct  being  involved  in 
the  inflammation,  may  have  its  canal  obliterated.  To  this 


153 

may  be  added,  as  a  third  cause  of  obliteration,  a  scirrhous^ 
or  any  other  enlargement  of  the  round  head  of  the  pancreas, 
which  may  so  press  upon  the  lower  extremity  of  the 
ductus  communis  choledochus,  as  to  annihilate  its  cavity. 
It  has  only  occurred  to  myself  to  have  seen  an  instance  of 
obliteration  in  the*  ductus  cysticus;  but  Dr.  Storer  of 
Nottingham,  whose  ability  and  industry  in  his  profession 
are  well  known,  has  favoured  me  with  an  account  of  two 
cases  of  obliteration  at  the  end  of  the  ductus  communis 
choledochus. 

A  preternatural   Canal  of  Communication   between  the 
Gall-bladder  and  the  stomach. 

It  may  not  be  improper  to  take  notice  here,  that  I  have 
once  seen  an  immediate  communication,  by  a  short  canal, 
between  the  gall-bladder  and  the  small  end  of  the  stomach. 
This  lusus  naturae  is  very  rare,  and  but  a  few  instances  of 
it  have  been  recorded. 

Gall-  Stones. 

It  is  not  an  uncommon  appearance  of  disease  in  exam- 
ining dead  bodies,  to  find  gall-stones,  either  in  the  gall- 
bladder,  or  in  some  of  the  biliary  ducts.  The  gall-bladder 
is  sometimes  much  enlarged  in  its  size,  and  full  of  them. 
In  this  case  its  coats  are  often  a  good  deal  thickened, 
which  arises  partly  from  the  pressure  against  the  gall- 
bladder, in  consequence  of  the  accumulation  of  the  stones, 
and  partly  from  the  efforts  of  the  contractile  power  of  the 
gall-bladder,  to  expel  them.  The  number  of  stones  ac- 
cumulated in  the  gall-bladder  is  sometimes  very  great; 
above  a  thousand  have  been  take,n  out  of  one  gall-bladder, 
which  are  preserved  in  Dr.  Hunter's  collection.  When 
U 


154 

there  is  a  solitary  gall-stone  in  the  gall-bladder,  it  is  occa- 
sionally very  large;  I  have  known  an  instance  of  one  which 
was  fully  the  size  of  a  hen's  egg.  When  there  is  but  one 
gall-stone  either  in  the  gall-bladder,  or  in  the  biliary  ducts, 
it  is  generally  of  an  oval  shape ;  when  there  is  a  consid- 
erable number,  they  acquire  by  rubbing  upon  each  other, 
in  a  small  space,  a  great  many  sides  and  angles. 

There  is  great  variety  in  the  external  appearance  of 
gall-stones  with  respect  to  colour :  some  are  whitish, 
others  are  black ;  they  are  also  of  a  yellowish,  a  greenish, 
a  light  brown,  a  dark  brown,  and  a  reddish-brown  colour. 
These  are  the  principal  varieties  in  colour,  but  there  are 
many  other  smaller  differences  which  it  is  very  difficult 
to  express  in  words.  .Gall-stones  differ  also  very  much  in 
the  state  of  their  surface,  some  being  very  smooth,  and 
others  a  good  deal  roughened. 

When  cut  or  broken,  gall-stones  are  commonly  found 
to  consist  of  concentric  laminae  upon  the  outside,  and  in 
the  centre,  of  a  radiated  structure.  The  laminated  part 
bears  sometimes  a  large  proportion  to  the  other,  and 
sometimes  the  contrary  happens.  The  laminated  and 
radiated  structures  are  sometimes  compact,  and  sometimes 
consist  of  a  more  loose  matter.  It  likewise  occasionally 
happens  that  both  the  laminated  and  the  radiated  structures 
are  very  obscure,  and  the  gall-stone  appears  a  good  deal 
like  an  uniform  solid  mass.  The  laminated  part  on  the 
outside  very  frequently  consists  of  a  different  substance  in 
appearance,  from  the  radiated  structure  in  the  centre;  and 
it  is  not  unusual  to  find  the  structure  in  the  centre  to 
consist  of  shining  white  crystallizations,  which  have  a 
good  deal  the  look  of  mica  or  spermaceti. 


155 

Gall-stones  being  very  different  both  in  their  outward 
appearance  and  their  internal  structure  from  each  other, 
we  are  naturally  led  to  suppose  that  they  may  also  differ 
in  their  chemical  properties.  Upon  this  subject  I  can  only 
speak  generally;  but  such  trials  as  I  have  made,  incline- 
me  to  this  opinion.  Very  few  gall-stones  yield  a  bitter 
taste,  which  shews  that  commonly  they  do  not  consist  of 
inspissated  bile ;  but  in  some  I  have  found  the  taste 
intensely  bitter.  Almost  all  of  them  melt  in  the  flame  of 
a  candle ;  but  I  have  met  with  one  sort  of  a»  very  black 
colour,  which  did  not  melt,  but  burnt  exactly  like  a  cinder.* 

All  the  gall-stones  which  I  have  examined  dissolve  in 
the  nitric  acid.  They  are  separated  into  a  fine  black 
powder  when  put  into  the  sulphuric  acid,  especially  if 
exposed  to  a  sand  heat.  By  the  muriatic  acid  they  are 
not  acted  upon  at  all  in  the  common  heat  of  the  atmosphere; 
and  are  even  but  little  affected  by  it  when*  exposed  to  a 
sand  heat  for  a  considerable  time. 

Most  of  the  gall-stones  which  I  have  examined,  are 
either  not  very  soluble  in  oil  of  turpentine  in  the  common 
heat  of  the  atmosphere,  or  the  process  goes  on  very  slowly: 
one  sort  I  have  found  to  be  in  this  heat  altogether  insoluble. 
When  put  into  this  oil,  and  exposed  to  a  sand  heat, 
they  are  much  more  readily  acted  upon.  Some  are  con- 
verted into  a  kind  of  oil,  which  sinks  to  the  bottom  of  the 
oil  of  turpentine ;  others  are  partly  soluble,  tinging  the  oil 
of  turpentine  of  a  brownish  colour,  and  are  partly  separated 
into  a  powder. 

*  Dr.  Soemmerring  considers  these  as  inspissated  bile,  and  mentions,  that 
they  have  no  regular  form,  have  a  bitter  taste,  and  are  soluble  in  water.  In  some 
trials  which  I  made,  they  did  not  dissolve  in  distilled  water,  either  cold  or  hot; 
but  they  are  bitter  to  the  taste,  and  without  any  regular  shape,  or  appearance 
of  crystallization., 


Most  gall-stones  appear  not  to  be  readily  affected  by 
spirit  of  wine  in  the  common  heat  of  the  atmosphere,  but 
are  either  partly  or  entirely  soluble  in  it  in  a  boiling  heat.* 
Such  are  the  general  results  from  a  good  many  trials  of 
my  own,  but  although  I  have  paid  a  good  deal  of  attention 
to  chemistry  at  an  early  period  of  my  life,  I  should  rest 
upon  them  with  little  confidence,  if  they  did  not  in  a  great 
measure  correspond  with  those  of  the  experiments  of 
others  who  are  more  conversant  than  myself  bocli  with  the 
scientific  and  practical  parts  of  chemistry. 

Gall-stones  according  to  the  experiments  of  Gren, 
consist  of  a  substance  possessing  the  properties  of  wax 
and  of  lymph,  f 

A  gall-sione,.  consisting  of  a  chocolate  coloured  sub- 
stance on  the  outside  and  of  white  radiated  lamellae  upon 
the  inside,  was  found  by  Dr.  Saunders  to  consist  of  a 
resinous  matter,  with  a  small  proportion  of  earth,  appar- 
ently the  calcareous,  and  some  mineral  and  volatile  alkali.  J 

The  gall-stones  which  Dr.  Powell  examined  were  found 
to  consist  of  resinous  matter,  carbon,  and  an  animal  sub-, 
stance  resembling  dried  mucus. §     This  subject  seems  still 
to  be  imperfectly  known,  and  to  require  further  investigation. 


*  When  some  biliary  calculi  are  exposed  to  spirit  of  wine  in  a  boiling  state, 
white  flaky  crystals  are  soon  formed  upon  its  cooling.  When  they  are  exposed 
to  spirit  of  wine  in  the  common  heat  of  the  atmosphere,  it  is  some  weeks 
before  crystals  begin  to  be  formed,  and  they  appear  to  be  more  pointed  in 
their  shade  than  the  former.  These  crystals  were,  I  believe,  first  observed 
by  M.Poulletier  de  la  Salle.  See  Elemens  d'Histoire  Naturelle  et  de  Chimie, 
par  M.  de  Fourcroy,  Tom.  IV.  p.  354. 

f  See  Johnson's  Animal  Chemistry,  Vol-  II.  p.  355- 

t  See  Dr.  Saunders's  Treatise  on  the  liver,  p.  119,  first  edition. 

§  See  Dr.  Powell's  Observations  on  the  Bile  and  its  Diseases. 


157 


Bile. 

The  bile  in  the  gall-bladder  is  found  to  differ  in  different 
bodies ;  but  this  is  too  common  to  arise  from  disease,  and 
must  depend  on  natural  circumstances.  It  is  sometimes 
of  a  green,  at  other  times  of  a  brownish  yellow,  or  a  purer 
yellow  colour.  The  brownish  yellow  colour  is  the  most 
common.  It  is  always  more  or  less  viscid,  and  the  variety 
in  this  respect  is  considerable :  in  man  it  generally  appears 
a  good  deal  more  viscid  than  in  most  other  classes  of 
animals.  In  one  case,  I  have  seen 'it  as  ropy  as  the  mucus 
which  is  commonly  coughed  up  from  the  trachea.  I 
recollect  also  another  case,  where  the  bile  in  the  gall-bladder 
resembled  exactly  the  white  of  a  raw  egg.  This  kind  of 
substance  is  ascertained  to  form  one  of  the  constituent 
parts  of  the  bile,  and  in  the  present  instance  it  would  seem 
that  the  other  parts  were  wanting.  Such  an  effect  may 
be  supposed  to  have  depended  upon  a  very  imperfect 
action  of  the  secretory  structure  of  the  liver.  The  liver  in 
this  case  was  not  sound,  being  studded  with  scrofulous 
tubercles,  and  the  absorbent  glands  of  the  mesentery  were 
affected  with  the  same  disease. 

In  opening  dead  bodies,  the  bile  is  almost  always  found 
to  have  transuded  in  small  quantity  through  the  coats  of 
the  gall-bladder,  so  as  to  tinge  the  neighbouring  parts, 
especially  the  small  end  of  the  stomach,  and  the  beginning 
of  the  duodenum.  This  is  to  be  considered  as  a  natural 
effect,  which  has  taken  place  after  death,  and  not  as  a 
diseased  appearance.  The  coats  of  the  gall-bladder,  in 
consequence  of  death,  have  lost  that  compactness  by  which 
they  were  formerly  able  to  confine  the  bile ;  it  therefore  tran- 
sudes in  small  quantity,  and  tinges  the  neighbouring  parts. 


158 


The  Gall-bladder  distended  with  Bile. 

The  gall-bladder  is  sometimes  distended  with  bile  so  as 
to  be  of  nearly  twice  its  usual  size;  at  other  times,  there 
is  no  bile  at  all  in  its  cavity,  and  under  such  circumsances 
it  is  white  in  its  colour,  and  contracted  into  very  small  size. 

Hydatids  in  the  Gall-bladder. 

'*'  The  gall  bladder  has  been  known  to  be  distended  to  an 
immense  size,  and  to  contain  hydatids;*  but  this  state  of 
it  is  to  be  considered  as  extremely  uncommon. 

The  Gall-bladder  -wanting. 

The  gall-bladder  has  also  been  known  to  be  wanting 
from  a  defect  in  the  original  formation.-)"  It  has  never 
occurred  to  me,  to  see  an  example  of  this  kind  of  mon- 
strosity; but  it  may  be  the  more  readily  believed  some- 
times to  happen,  as  the  gall-bladder  does  not  serve  any 
necessary  purpose  in  the  body.  There  are  many  classes 
of  animals  which  are  naturally  without  a  gall-bladder. 


SYMPTOMS. 

Inflammation  of  the  coats  of  the  gall-bladder  is  not 
known  to  be  distinguished  by  any  peculiar  symptoms. 
They  are  probably  much  the  same  with  the  symptoms 


•Sec  Medical  Communications,  Vol.  I.  p.  101. 
t  See  Dr.  Soemmering's  Germ.  Translat.  p.  150, 


159 

which  attend  inflammation  of  the  membranous  covering 
of  the  liver. 


An  obliteration  either  of  the  hepatic  duct  or  of  the 
ductus  communis  choledochus,  must  produce  a  jaundice 
which  is  permanent,  because  it  depends  upon  a  cause 
not  liable  to  change.  This  will  be  extremely  difficulty 
to  distinguish,  in  practice,  from  jaundice  produced  by  a 
hardened,  or  tuberculated  state  of  the  liver,  for  this  cause 
of  jaundice  may  likewise  be  said  to  be  generally  permanent. 
When  the  ductus  cysticus  only  is  obliterated,  there  will 
be  no  jaundice,  and  little  inconvenience  will  probably  be 
felt,  unless  the  bile  confined  in  the  gall  bladder  should  at 
length  irritate  its  coats.  In  this  case  inflammation  may 
be  excited,  which  may  advance  to  suppuration.  I  have 
seen  an  ulcer  of  the  gall-bladder,  which  appeared  to  be 
produced  by  this  cause. 


While  gall-stones  remain  in  the  gall-bladder,  and  no 
attempt  is  made  towards  their  passing  through  the  ductus 
cysticus,  and  ductus  communis  choledochus,  very  little 
inconvenience  is  commonly  produced  by  them.  It 
frequently  happens  that  gall-stones  are  found  in  the  gall- 
bladder after  death,  where  there  was  notlhe  least  suspicion 
of  their  existence  during  life.  When  they  pass  through 
the  ducts,  more  especially  if  they  be  large  in  their  size, 
a  most  excruciatingtpain  is  commonly  felt  about  the  pit 
©f  the  stomach:  patients  in  this  case  express  a  muck 


160 

stronger  feeling  of  pain,  than  during  a  violent  inflamma- 
tion even  in  the  most  sensible  parts  of  the  body.  They 
often  cry  out,  and  writhe  or  twist  their  body  into  various 
postures.  When  the  pulse  is  felt  during  this  exquisite 
pain,  it  is  sometimes  found  to  be  accelerated  in  a  very 
trifling  degree,  but  generally  it  is  not  more  frequent  than 
in  health,  and  sometimes  it  is  even  slower.  There  is 
languor,  sickness,  and  vomiting;  and  the  skin  becomes  in 
the  progress  of  the  disease  more  or  less  of  a  yellow  colour. 


161 


CHAPTER  XL 


DISEASED   APPEARANCES   OF   THE   SPLEEN. 

Inflammation .  of  the  Coats  of  the  Spleen. 

THE, coats  of  the  spleen  are  liable  to  inflammation; 
but  this  rarely  takes  place  unless  the  peritonaeum  in  the 
neighbourhood  be  also  affected.  The  proper  capsule  of 
the  spleen  is  so  intimately  connected  with  the  peritonaeum 
which  is  reflected  over  it,  that  it  must  necessarily  partake 
of  any  inflammation  affecting  that  portion  of  the  membrane* 
When  inflammation  attacks  the  coats  of  the  spleen,  it 
exhibits  exactly  the  same  appearances  which  have  been 
so  often  described.  They  become  much  more  crowded 
with  florid  blood  vessels  than  in  a  natural  state,  are  some- 
what thicker,  and  throw  out  a  layer  of  coagulable  lymph 
upon  their  surface. 

Adhesions. 

It  is  more  common,  however,  to  find  adhesions  formed 
between  the  spleen  and  the  neighbouring  parts,  than  to 
find  its  coats  in  an  actual  state  of  inflammation.  These 
adhesions  consist  of  a  white  transparent  membrane  of  more 
or  less  firmness,  and  generally  connect  the  broad  surface 
of  the  spleen,  more  or  less  closely  to  the  diaphragm. 
They  often  connect  also  the  spleen  to  the  great  end  of  the 
stomach,  and  a  part  of  the  transverse  arch  of  the  colon. 
X 


162 


Coats  of  the  Spleen  Cartilaginous. 

The  coats  of  the  spleen  are  sometimes  converted  into 
cartilage;  and  this  disease  may  be  considered  in  a  great 
measure  as  peculiar  to  the  spleen.  It  is,  at  least,  much 
more  common  in  this  viscus  than  in  any  other. 

The  cartilage  is  generally  to  be  found  on  the  convex 
surface  of  the  spleen,  and  extends  over  more  or  less  of  it 
in  different  cases.  It  is  much  thicker  in  one  case  than 
another:  in  some  being  not  thicker  than  a  shilling,  and 
in  others  being  four  times  as  thick.  It  is  generally  formed 
in  a  smooth  layer,  but  occasionally  it  is  somewhat  irregu- 
lar. I  have  also  seen  in  some  instances  small  spots  of 
cartilage  over  the  whole  surface  of  the  spleen-  It  would 
appear  that  ossifications*  are  sometimes  to  be  found  in 
this  cartilage,  but  in  the  cases  which  have  come  under 
my  own  examination,  bony  matter  was  not  to  be  observed. 
The  cartilage  into  which  the  coats  of  the  spleen  are 
changed,  is  in  general  a  good  deal  softer  than  that  which 
covers  the  extremities  of  bones.  This  diseased  process, 
it  is  natural  to  think,  is  slow  in  its  progress,  can  hardly 
produce  any  impediment  to  the  functions  of  the  spleen, 
and  is  probably  not  marked  by  any  peculiar  feelings  to 
the  patient. 

Inflammation  of  the  Substance  of  the  Spleen. 

It  is  very  rare  to  find  the  substance  of  the  spleen  either 
in  a  state  of  inflammation  or  suppuration;  but  such  cases 
have  occasionally  been  observed  and  related  by  authors,  f 

*  Morgagni  has  seen  ossification  of  a  part  of  the  capsule  of  the  spleen 
Vid.  Epist.  X  Art.  19  Epist.  XIV.  Art.  23. 
f  Vid.  Lieutaud,  Tom.  I.  p  22. 
Vid.  Portal's  Anatomic  Medicate,  Tom.  V.  p.  333.  and  334, 


163 

Instances  also  have  been  related  where  the  spleen  had  been 
observed  to  be  mortified;*  but  this  is  probably  much 
more  rare  than  the  former. 

The  Spleen  extremely  soft. 

There  is  an  appearance  of  the  spleen  which  is  very 
common,  and  which  perhaps  is  hardly  to  be  considered 
as  a  disease,  but  it  is  a  very  obvious  deviation  from  its 
healthy  structure.  The  appearance  to  which  I  allude  is 
an  extreme  softness  of  the  spleen,  so  that  when  its  capsule 
is  broken  (which  under  such  circumstances  is  very  tender) 
the  substance  of  the  spleen  seems  to  consist  of  little  else 
than  a  very  soft,  brownish-red  mucus,  intermixed  with 
a  spongy  fibrous  texture.  This  appearance  of  the  spleen 
is  hardly  ever  to  be  observed  at  a  very  early  period  of  life, 
but  is  very  common  in  middle  and  more  advanced  age. 
I  believe  that  such  a  state  of  the  spleen  is  not  marked  by 
any  peculiar  feelings,  so  as  to  make  the  persons  conscious 
of  any  disease  taking  place,  and  is  probably  of  very  little 
consequence  in  the  general  economy  of  the  animal.  Still, 
however,  it  is  not  a  state  into  which  the  spleen  naturally 
degenerates  in  the  gradual  decay  of  the  body. 

The  Spleen  very  hard. 

The  spleen  is  sometimes  much  harder  than  natural,  and 
at  the  same  time  is  generally  a  good  deal  enlarged.  It  will 
occasionally  be  enlarged  to  five  or  six  times  its  natural 
size,  and  it  then  forms  a  tumour,  very  capable  of  being 
distinguished  by  an  examination  in  the  living  body. 
When  cut  into,  the  natural  structure  seems  to  be  pre* 

*  Vid,  Lientaud,  Tom,  I.  p.  226. 


164 

served,  except  that  it  is  much  more  compact,  or  solid  than 
it  ought  to  be. 

This  state  of  the  spleen  is  generally  considered  as 
scirrhous ;  but  its  structure  is  not  similar  to  scirrhus  in 
other  parts  of  the  bodyi  and  its  real  nature  is  probably 
at  present  not  fully  understood.  When  the  spleen  is  in 
this  state,  water  is  sometimes  accumulated  in  the  cavity 
of  the  abdomen. 

Tubercles  in  the  Spleen. 

The  spleen  is  sometimes,  although  rarely,  studded  in  its 
substance  with  small  tubercles,  very  similar  to  the  scro- 
fulous tubercles  of  the  lungs.  In  one  instance  1  have  seen 
some  of  these  in  a  state  of  suppuration,  and  the  pus  was 
thick  and  curdly,  like  scrofulous  pus. 

Spleen  very  large. 

The  spleen  is  sometimes  found  to  be  much  larger  in  its 
size  than  natural,  but  with  a  structure  perfectly  healthy; 
and  this  more  commonly  happens  to  the  spleen  than  to 
any  other  viscus.  Although  it  may  be  looked  upon  as  a 
monstrous  growth  of  the  spleen,  rather  than  a  disease,  yet 
it  may  produce  inconvenience  by  its  pressure,  and  by 
altering  in  some  degree  the  situation  of  the  neighbouring 
viscera. 

Hydatidsin  the  Spleen. 

Hydatids  are  occasionally  formed  in  the  spleen,*  which 
are  of  the  same  kind  with  those  of  the  liver;  but  they  are 
much  more  common  in  the  latter  viscus,  than  in  the 
former. 

*  Vid.  Morgagni,  Epist.  XXXVIII.  Art,  34* 


165 


Stony  Concretions  in  the  Spleen. 

Stony  concretions*  have  been  found  occasionally  in  the 
spleen;  but  such  cases  are  very  rare,  and  have  not  fallen 
under  my  own  observation. 

The  Spleen  Ruptured. 

The  spleen  has  been  known  sometimes  to  be  ruptured, 
in  consequence  of  external  pressure  upon  that  side  of  the 
body  where  it  is  situated.  When  the  spleen  is  of  the 
common  size,  an  accident  of  this  kind  can  very  rarely 
take  place,  because  it  is  well  defended  by  the  ribs  of  the 
left  side;  but  when  the  spleen  is  very  large,  so  that  a  part 
of  it  passes  below  the  margin  of  the  ribs  into  the  cavity  of 
the  flank,  such  an  accident  may  very  readily  happen. 

.     Several  small  Spleens. 

There  is  a  variety  in  the  natural  formation  of  the  spleen, 
which  I  believe  does  not  take  place  in  that  of  any  other 
gland  in  the  body.  It  consists  in  several  small  spleens 
being  formed  besides  the  common  one.  They  vary  in 
their  size  in  different  instances,  but  I  have  seen  some  of 
them  as  large  as  a  walnut.  They  are  situated  in  the 
omentum,  near  the  great  end  of  the  stomach,  are  supplied 
with  blood  vessels  from  the  splenic  artery  and  vein,  and 
have  exactly  the  same  structure  as  a  common  spleen.  It 
will  probably  make  no  difference  with  regard  to  the  use  of 
the  spleen,  whether  it  be  entirely  formed  of  one  mass,  or 
whether  it  consists  of  several  distinct  parts. 

*  Vid.  Lieutaud,  Tom,  I.  p,  231. 


166 


Spleen  said  to  be  wanting. 

The  spleen  has  been  said  to  be  occasionally  wanting, 
as  a  defect  in  the  natural  formation,  but  this  too  is  very 
uncommon.*  We  know  that  an  animal  is  capable  not  only 
of  existing,  but  also  of  enjoying  apparent  good  health  with- 
out a  spleen.  The  spleen  has  been  cut  out,  by  way  of 
experiment,  from  some  quadrupeds,  and  they  did  not 
appear  to  suffer  any  inconvenience  from  the  want  of  it. 
The  human  spleen  has  even  been  removed  in  a  few 
instances,  and  the  persons  have  not  only  recovered,  but 
have  enjoyed  afterwards  good  health.  It  does  not  appear^ 
therefore,  very  wonderful  that  a  body  should  be  formed 
without  a  spleen,  and  c^rry  on  its  vital  functions  without 
any  obvious  imperfection. 


SYMPTOMS. 

When  inflammation  attacks  the  coats  of  the  spleen,  it  is 
attended  with  the  same  symptoms  as  an  inflammation  of 
that  portion  of  the  peritonaeum,  which  lies  in  the  left 
hypochondrium.  There  is  pain  in  that  region,  which  is 
more  or  less  acute,  according  to  the  degree  of  the  inflam- 
mation; and  this  pain  is  increased  upon  pressure  immedi- 
ately upon  the  inside  of  the  left  margin  of  the  ribs.  If  the 
inflammation  be  considerable,  it  is  accompanied  with 
symptomatic  fever. 

*  Vid.  Lieutaud,  Tom.  I.  p.  234. 


167 


The  symptoms  which  have  been  described  as  belonging 
to  inflammation  of  the  substance  of  the  spleen,  are  a 
fullness  and  sense  of  pain  in  the  left  hypochondrium.  The 
pain  is  increased  upon  pressure,  and  there  is  more  or  less 
of  symptomatic  fever.  In  two  cases  of  inflamed  spleen, 
examined  by  the  late  Dr.  Hunter,  where  the  inflammation 
had  advanced  to  suppuration,  the  patients  could  not  define 
accurately  the  seat  of  their  pain,  but  the  pain  seemed  to 
travel  a  good  deal  over  the  general  cavity  of  the  abdomen. 
In  some  instances  palpitation  of  the  heart,  difficulty  of 
breathing,  and  vomiting  have  been  observed  to  take  place 
in  this  disease. 


An  enlarged  and  hardened  state  of  the  spleen  is  not 
suspected  or  known,  till  the  disease  has  made  a  considera- 
ble progress,  so  that  the  spleen  is  capable  of  being  felt  ex- 
ternally. It  is  commonly  attended  with  no  pain,  and  will 
even  bear  a  pretty  strong  pressure,  without  any  painful 
sensation.  It  may  be  distinguished  when  the  spleen  has 
arrived  at  a  considerable  size,  by  the  situation  and  the 
general  shape  of  the  tumour.  The  anterior  edge  of  the 
spleen  can  generally  be  felt  distinctly  by  the  hand  applied 
to  the  surface  of  the  abdomen,  under  the  margin  of  the 
ribs  upon  the  left  side ;  and  the  edge  is  sometimes  dis- 
tinguished by  this  examination  to  be  notched.  This 
state  of  the  spleen  is  often  at  length  attended  with  dropsy. 


There  are  no  peculiar  syrastoms  which  characterize  the 


168 

formation  of  hydatids  in  the  spleen.  A  pain  has  been 
remarked  to  be  felt,  in  such  cases,  in  the  left  hypochon- 
drium ;  but  this  also  belongs  to  many  other  complaints. 
When  a  swelling  begins  in  the  situation  of  the  spleen,  and 
spreads  very  slowly  into  the  cavity  of  the  abdomen,  being 
somewhat  soft  to  the  feeling,  and  perhaps  giving  some 
obscure  sense  of  fluctuation,  the  disease  may  then  be 
reasonably  supposed  to  depend  on  the  formation  of  hyda- 
tids in  this  organ. 


169 


CHAPTER  XII. 


DISEASED    APPEARANCES  OF   THE   PANCREAS. 

THE  pancreas  is  subject  to  very  few  diseases.  It  seU 
dom  happens,  upon  examining  dead  bodies,  that  it  exhibits 
any  other  than  the  healthy  structure. 

Abscess  of  the  Pancreas. 

Inflammation  is  very  little  apt  to  affect  the  pancreas. 
It  has  only  occured  to  me  to  see  one  instance  of  an  abscess 
formed  jn  it.  It  was  a  good  deal  enlarged  in  its  size,  and 
contained  a  considerable  quantity  of  thin  pus.^ 

Pancreas  hard. 

It  is  not  very  uncommon  ^to  find  the  pancreas  much 
harder  than  in  its  natural  state,  and  at  the  same  time  it  is 
thicket  and  shorter  than  usual.  There  is,  however,  little 
appearance  to  the  eye  of  its  structure  being  altered.  This 
I  believe  to  be  the  beginning  of  a  process,  by  which  the 
pancreas  become  truly  scirrhous.  It  very  seldom  in  this 
state  shews,  in  any  part,  the  real  scirrhous  structure.  But 
I  have  seen  this  to  be  the  case,  which  renders  it  very 
probable,  that  the  one  is  the  beginning  of  a  change  into 
the  other.  When  the  pancreas  in  any  part  assumes  the 
scirrhous  structure,  that  part  loses  entirely  its  natural 
appearance,  and  is  converted  into  a  hard  uniform,  white 

*  Portal  however  has  met  with  several  instances  of  abscess  in  the  pancreas, 
and  has  even  seen  it  in  some  cases  mortified,  Vid.  Tom.  V.  p.  351,  353  and  353 

Y 


170 

mass,  intersected  by  membranes,  like  scirrhus  in  other 
parts  of  the  body.  In  some  cases  it  has  been  observed, 
in  this  state,  to  be  considerably  enlarged. 

Calculi  of  the  Pancreas. 

Calculi  are  occasionally  formed  in  the  ducts  of  the 
pancreas.  Of  this  I  have  known  only  one  instance.  The 
calculi  were  about  the  size  of  the  kernel  of  a  hazel  nut, 
with  a  very  irregular  surface,  and  of  a  white  colour. 
These  stones  dissolved  in  muriatic  acid  with  the  extrac- 
tion of  a  large  quantity  of  carbonic  gas,  and  are  found  to 
consist  of  carbonated  lime.*  It  is  not  improbable,  that 
calculi  formed  in  the  pancreas  may  differ  somewhat  from 
each  other,  as  we  find  to  happen  in  other  calculi  which  arc 
formed  in  the  body ;  but  as  this  is  a  very  rare  disease  in 
the  pancreas,  it  must  be  a  long  time  before  this  point  can 
be  fully  ascertained. 

Steatomatous  Tumours. 

Steatomatous  tumours  have  been  sometimes  found 
adhereing  to  the  pancreas,  but  this  morbid  appearance  is 
extremely  rare.f 

Pancreas  wanting 

The  pancreas  has  been  said  to  be  entirely  wanting,  as 
a  defect  in  the  original  formation 4" 

*  See  Dr.  Pemberton's  Treatise  upon  the  Abdominal  Viscera,  p.  9%* 
f  Vid.  Portal's  Anatomie  Medicale,  Tom.  V.  p.  356. 

*  Vid.  Lieutaud,  Tom.  I.  p.  247. 


171 


SYMPTOMS. 

I  have  only  had  one  opportunity  of  seeing  an  abscess 
in  the  pancreas.  It  was  in  a  young  man,  a  little  beyond 
the  age  of  twenty.  He  did  not  complain  of  any  fixed  pain 
in  the  situation  of  the  pancreas,  but  had  a  good  deal  of 
pain  in  different  parts  of  the  abdomen.  This  seemed  to 
be  connected  with  spasmodic  contractions  of  the  intestinal 
canal,  which  inclosed  portions  of  wind,  and  also  with 
spasms  of  the  abdominal  muscles.  There  was  sickness 
and  distention  of  the  stomach  more  especially  after  eating, 
and  the  food  likewise  sometimes  occasioned  a  sense  of 
weight  in  that  organ.  He  had  a  disposition  to  purging ; 
made  but  little  water ;  and  became  at  length  dropsical. 
His  pulse  was  commonly  about  eighty.*  In  some  cases 
which  are  related  in  books,  I  find  that  patients  with 
abscesses  in  the  pancreas  have  commonly  complained  of 
pain  in  the  back  and  lions,  but  they  seem  to  have  had  no 
peculiar  symptoms. 


When  the  pancreas  becomes  harder  than  in  its  healthy 
state,  it  is  often,  I  believe,  not  attended  with  any  painful 
sensations  to  the  patient  which  are  well  defined.  But  it 
sometimes  happens,  although  rarely,  that  the  pancreas 
becomes  much  enlarged  in  its  size,  as  well  as  hard  in  its 
structure,  undergoing  those  changes  which  belong  to 
scirrhus.  In  such  cases,  a  long  continued  pain  has  been 

*  For  the  account  of  the  symptoms  in  the  above, case,  I  am  indebted  t'o 
Dr.  Wm,  Herberden. 


172 

remarked  to  exist  in  the  epigastric  region,  and  the  stomach 
has  been  affected  with  sickness.  In  one  instance,  of 
which  I  have  heard  an  account,  besides  the  symptoms 
already  mentioned,  there  was  a  pain  in  the  hips,  and  a 
sense  of  numbness  in  one  thigh  and  leg. 


I  am  not  acquainted  with  the  symptoms  which  are 
produced  by  the  formation  of  calculi  in  the  pancreas.  If 
the  calculi  should  happen  to  be  smooth  and  few  in  num- 
ber they  would  probably  occasion  little  pain  or  incon- 
venience. But  if  they  should  be  rough  upon  their 
surface  and  numerous,  they  would  probably  produce  a 
good  deal  of  irritation  and  pain  in  the  pancreas,  together 
with  sickness  and  vomiting;  but  it  is  not  likely  that  we 
should  be  able  to  guess  at  the  cause  of  the  irritation,  unless 
some  of  the  calculi,  having  passed  into  the  duodenum,, 
should  be  evacuated  by  vomiting,  or  by  stool. 


173 


CHAP.  XIII, 


DISEASED  APPEARANCES    OF   THE   KIDNEYS   AND   THE 
RENAL    CAPSULES. 

Capsule  of  the  Kidneys  inflamed. 

I  do  not  recollect  to  have  seen  the  proper  capsule  of  the 
kidney  inflamed,  and  I  am  disposed  to  consider  it  as  a 
rare  morbid  appearance.  The  reason,  probably,  why  it 
seldom  occurs,  is  that  the  peritonaeum  reflected  over  the 
surface  of  the  kidney  has  a  very  loose  connection  with  it, 
there  being  interposed  between  them  a  considerable  quan- 
tity of  cellular  membrane  and  fat.  It  seems  very  likely 
that  the  principal  reason  why  the  capsules  of  some  other 
glands  in  the  abdomen  are  so  frequently  inflamed,  is  their 
close  connection  with  the  peritonaeum ;  which  membrane, 
from  circumstances  it  is  perhaps  difficult  to  ascertain,  is 
very  liable  to  inflammation.  When  the  capsule  of  the 
kidneys  is  inflamed,  the  same  appearances  of  inflammation 
will  take  place,  which  have  been  so  often  noted. 

Mscesses  of  the  Kidneys. 

When  the  substance  of  the  kidneys  is  inflamed,  it 
frequently  advances  to  suppuration,  and  perhaps  there  is 
no  considerable  gland  in  the  body  so  liable  to  form  abscesses 
as  the  kidneys.  In  some  cases  which  I  have  seen,  the 
abscesses  have  appeared  to  be  of  a  common  nature ;  but  in 
the  greater  number  of  cases,  they  have  been  scrofulous. 

When  a  kidney  is  attacked  with  scrofula,  and  the 


174 

disease  lias  advanced  to  suppuration,  it  exhibits  different 
appearances,  according  to  the  progress  it  has  made. 
Sometimes  there  are  only  one  or  two  circumscribed 
abscesses,  containing  a  curdly  pus,  without  any  thing 
being  particularly  observable  in  the  inner  surface  of  the 
abscesses.  Frequently,  however,  the  inner  surface  of  the 
abscesses  is  lined  with  a  pulpy  matter.  These  abscesses 
generally  first  destroy  the  mamillary  portion  of  the  kidney; 
and  when  they  advance  very  far,  they  destroy  almost  the 
whole  structure  of  the  kidney,  converting  it  into  capsules 
which  surround  a  number  of  imperfect  cavities  that  are 
lined  with  this  pulpy  substance. 

The  capsule  into  which  a  kidney  is  changed  by  the 
progress  of  this  disease,  is  on  some  occasions  thicker 
than  on  others,  frequently  of  considerable  hardness,  and 
seems  sometimes  to  be  slightly  laminated,  When  a 
kidney  is  so  affected,  it  is  not  uncommon  for  the  pelvis 
and  ureter  to  partake  of  the  disease,  and  a  calculus  is 
sometimes  found  either  in  the  abscess,  or  in  the  pelvis  of 
the  ureter.  In  some  cases  of  this  kind,  a  considerable 
number  of  calculi  have  been  found.* 

Scrofulous  Tubercles  in  the  Kidneys. 

It  is  not  unusual  (as  we  have  stated  above)  for  scrofulous 
abscesses  to  take  place  in  the  kidneys,  but  it  occurs  very 
rarely  that  scrofulous  tubercles  are  formed  in  them.  I 
have  seen,  however,  an  instance  of  this  kind,  and  the 
tubercles  resembled  most  exactly  the  common  tubercles 
of  the  lungs.  None  of  them  were  in  a  state  of  suppuration. 

*  In  such  cases,  it  is  very  probable  that  the  calculus  or  calculi  are  the 
immediate  cause  of  the  other  disease,  the  constitution  being  at  the  same  time 
disposed  to  it.  By  the  irritation  of  the  calculi,  inflammation  and  suppuration 
are  produced  in  the  kidney,  and  these  partake  of  the  nature  of  the  constitution. 


175 


Kidney  scirrhous. 

The  kidney  I  have  once  seen  converted  into  a  hard, 
uniform  substance,  somewhat  intersected  by  membrane, 
in  which  the  natural  structure  of  this  gland  was  entirely 
lost.  The  kidney  was  at  the  same  time  very  much  en- 
larged  in  its  size.  This  alteration  of  structure  I  should 
call  scirrhus,  because  it  exactly  resembles  scirrhus  in  other 
parts  of  the  body:  it  occurs  very  rarely  in  the  kidneys. 

State  of  the  Kidneys  in  Diabetes. 

Opportunities  do  not  frequently  occur  of  examining 
the  state  of  the  kidneys  in  diabetes.  I  have  once,  however, 
been  able  to  make  this  examination  in  a  satisfactory  man- 
ner, where  a  person  had  been  long  affected  with  diabetes, 
and  had  been  a  patient  under  my  care  in  St.  George's 
Hospital.  In  both  kidneys  the  superficial  veins  were 
much  fuller  of  blood  than  usual,  forming  upon  their  surface 
a  most  beautiful  network  of  vessels.  The  whole  substance 
of  the  kidneys  was  much  more  vascular  than  in  a  healthy 
state,  approaching  a  good  deal  in  appearance  to  what  takes 
place  in  inflammation.  In  both  of  them  there  was  a  very 
small  quantity  of  a  whitish  fluid,  somewhat  resembling 
pus:  but  there  was  no  appearance  of  ulceration  whatever. 
The  artery,  the  vein,  the  lymphatic  vessels,  and  the  nerves 
of  both  kidneys  were  in  their  natural  state.  The  liver,  at 
the  same  time,  I  examined  with  care,  because  it  has  been 
thought  by  some  to  be  the  chief  source  of  disease  in  diabetic 
patients,  but  it  was  perfectly  sound.  The  stomach  and 
intestines  were  also  examined  with  attention,  but  no  ap- 
pearances occurred  in  them  which  are  not  very  common. 


176 


Kidneys  very  soft. 

I  have  also  seen  the  substance  of  the  Iqdney  converted 
into  a  soft  loose  mass,  resembling  almost  exactly  the 
appearance  of  common  spunge.  On  the  surface  there 
were  many  round  interstitial  cavities  scattered  at  irregular 
distances ;  and  when  the  substance  of  the  kidney  was  cut 
into,  it  exhibited  the  same  spongy  structure.  The  blood 
vessels  of  the  kidney  were  seen  ramifying  very  distinctly 
through  the  spongy  mass.  There  was  no  appearance  of 
pus  in  the  kidney,  nor  was  there  the  most  distant  resem- 
blance between  this  process,  and  the  effects  produced  by 
suppuration.  It  was  a  process  of  a  peculiar  kind,  by 
which  a  considerable  portion  of  the  kidney  was  removed 
by  the  action,  probably,  of  absorbent  vessels  and  it 
seemed  to  act  much  more  on  the  cortical  than  the  tubular 
part  of  it.  I  am  not  at  all  exaggerating  the  effect  of  this 
diseased  process  when  I  say,  that  the  kidney  was  rendered 
fully  as  soft  as  a  common  sponge.  When  shaken  in 
water,  the  parts  all  separated  from  each  other,  somewhat 
like  the  unravelling  of  the  shaggy  vessels  of  the  placenta. 
Such  an  appearance  of  kidney,  but  in  a  much  smaller  de- 
gree, has  fallen  two  or  three  times  under  my  own  observation. 

Hychtids  of  the  Kidneys. 

The  formation  of  hydatids  is  not  an  uncommon  disease 
in  the  kidneys.  There  are  sometimes '  one  or  two  con- 
siderable hydatids  on  the  surface  of  the  kidney,  lying 
between  its  substance  and- capsule;  at  other  times,  they 
are  more  numerous.  These  hydatids  do  not  appear  to  be 
of  the  same  nature  with  the  hydatids  of  the  liver :  they  are 
not  inclosed  in  firm  cysts ;  their  coats  are  also  thinner,  and 


177 

less  pulpy;  and  not  uncommonly  they  are  almost  as  thin 
as  any  membrane  of  the  body.  I  do  not  recollect  to  have 
seen  any  instance  of  small  hydatids  of  this  sort  attached  to 
the  coats  of  larger  hydatids  in  the  kidney,  as  may  be 
frequently  observed  in  the  liver.  It  is  therefore  probable, 
that  the  hydatids  which  are  commonly  found  in  the  kidney, 
depend  on  a  diseased  alteration  of  the  structure  of  this 
organ,  and  are  not  distinct  organized  simple  animals. 

Sometimes,  however,  the  true  hydatid  is  formed  in  the 
kidneys,  having  exactly  the  same  nature  with  that  which 
grows  in  the  liver.  It  has  occured  to  me  to  be  able  to 
examine  particularly  a  case  of  this  kind  after  death,  and 
I  shall  describe  at  some  length  what  came  then  under  my 
observation.  The  right  kidney,  in  a  soldier,  was  conver- 
ted into  a  bag  capable  of  containing*  at  least  three  pints  of 
fluid,  and  only  a  very  small  part  of  the  kidney  at  the  lower 
end  retained  its  natural  structure.  The  bag  was  of  con- 
siderable thickness,  was  obscurely  laminated,  and  had  a 
cartilaginous  hardness  upon  its  inner  surface.  It  was  full 
of  hydatids,  which  differed  very  much  from  each  other  in 
their  size,  some  of  them  being  as  large  as  a  small  orange, 
and  others  not  larger  than  the  head  of  a  pin.  Some  of 
the  small  hydatids  were  lodged  in  little  cavities  formed  in 
the  inner  surface  of  the  bag.  Their  coats  were  in  general 
easily  separable  into  two  laminae,  and  varied  a  good  deal 
in  thickness  in  different  hydatids.  This  difference  made 
one  hydatid  look  opaque,  while  another  was  transparent. 
Even  in  the  same  hydatid  there  was  often  a  difference  in 
the  opacity,  or  transparency  of  its  coat  at  different  parts. 
Some  hydatids  had,  adhering  to  their  inner  surface,  a 
cluster  of  small  hydatids,  which  looked  like  small  pearls ; 
others  had  hydatids  even  of  a  considerable  size  floating 
Z 


178 

lobse  in  their  cavity ;  and  others  contained  only  a  fluid* 
The  fluid  in  many  was  transparent,  but  in  some  hydatids 
it  resembled  whey.  Some  of  the  small  hydatids  had  fre- 
quently been  passed  along  with  the  urine,  when  the  person 
was  alive.  It  required  an  increased  exertion  of  the  mus- 
cular power  of  the  bladder  to  drive  them  through  the 
urethra,  and  the  bladder,  by  this  exertion,  had  acquired  a 
stronger  muscular  coat,  as  in  other  cases  of  obstruction 
to  the  free  passage  of  the  urine. 

Calculi  of  the  Kidneys. 

The  formation  of  calculi  is  not  peculiar  to  the  kidneys, 
but  it  is  a  more  frequent  disease  in  them  than  in  any  other 
part  of  the  body.  Small  granules  of  stone  are  sometimes 
found  in  the  tubular  portion  of  the  kidneys;  but  it  is  more 
common  to  find  a  calculus  of  considerable  size  lodged 
either  in  some  part  of  the  substance  of  the  kidney,  or 
in  the  pelvis  of  the  ureter. 

The  last  situation  is  by  much  the  most  frequent.  When 
a  stone  in  its  situation  is  so  large  as  not  to  be  capable  of 
passing  through  the  ureter,  it  is  afterwards  gradually  in- 
creased in  size,  from  the  contact  of  the  urine.  In  its 
growth,  it  necessarily  follows  the  branches  of  the  pelvis, 
which  are  called  infundibula,  and  is  therefore  of  an  arbo- 
rescent form.  Such  calculi  vary  in  their  colour  and 
surface ;  they  are  sometimes  of  a  light  brown,  sometimes 
of  a  dark  brown,  and  sometimes  of  a  white  colour.  They 
are  also  sometimes  smooth,  and  sometimes  a  little  rough- 
ened  on  their  surface.  Of  the  nature  of  urinary  calculi 
we  shall  speak  afterwards,  when  we  come  to  take  notice 
of  the  diseased  appearances  of  the  bladder.  When  a  stone 
hi  the  pelvis  of  the  ureter  has  increased  to  a  very  consider- 


179 

able  size,  it  almost  entirely  prevents  the  urine  from  passing 
into  the  ureter.  The  urine  is  therefore  accumulated  in 
the  pelvis  above  the  stone,  and  hence  enlarges  the  pelvis 
very  much,  as  well  as  the  cavity  in  the  kidney  itself. 
From  the  pressure  too  of  the  urine  behind  the  stone,  the 
pelvis  of  the  ureter,  besides  being  enlarged,  is  thrust  out 
from  the  substance  of  the  kidney.  If  the  interruption  to  the 
passage  of  the  urine  from  the  kidney  arises  from  some  ob- 
struction in  the  lower  extremity  of  the  ureter,  or  at  the 
neck  of  the  bladder,  or  in  any  part  of  the  urethra,  not  only 
the  pelvis  of  the  ureter  is  then  enlarged,  but  the  ureter 
itself.  I  have  seen  the  ureters  of  both  kidneys  enlarged 
from  this  cause  to  twice  or  thrice  their  natural  size. 

Whatever  be  the  nature  of  the  obstruction,  if  the  pelvis 
of  the  ureter  be  very  much  enlarged  from  the  accumulation 
of  the  urine,  the  cavity  of  the  kidney  is  at  the  same  time 
enlarged.  As  this  process  advances,  the  substance  of  the 
kidney  becomes  more  and  more  compressed,  is  gradually 
absorbed,  and  its  cavity  becomes  enlarged  in  proportion. 
The  substance  of  the  kidney  is,  at  length,  in  a  great  mea- 
sure lost,  and  is  converted  into  a  capsule,  containing  a 
great  many  cells,  which  communicate  with  each  other. 
The  capsule  is  sometimes  very  thin,  and  the  whole  mass 
a  great  deal  larger  than  the  natural  size  of  a  healthy  kidney. 
It  is  worthy  of  remark,  that  the  urine  is  secreted  even 
when  the  natural  structure  of  the  kidney  is  almost  entirely 
lost.  This  is  seen  both  in  the  derangement  of  the  kidneys 
now  under  consideration,  and  when  they  are  converted 
into  a  mass  of  hydatids.  It  would  appear  from  this  fact, 
that  a  very  small  portion  of  the  natural  structure  of  the 
kidneys  is  capable  of  separating  very  nearly  the  ordinary 
quantity  of  the  urine. 


180 


Kidneys  earthy  and  bony. 

The  kidneys  have  been  said  to  be  converted  into  an 
earthy  substance.**  A  kidney  has  also  been  known  to 
become  ossified,  f  Such  appearances  have  never  come 
under  my  own  observation,  and  I  am  persuaded  are  ex- 
tremely rare. 

Original  Varieties  in  the  Kidneys. 

The  kidneys  are  subject  to  a  good  deal  of  variety  in 
their  natural  circumstances,  from  original  formation.  The 
two  kidneys  are  sometimes  found  to  be  joined  together: 
they  are  sometimes  situated  before  the  lumbar  vertebras, 
and  sometimes  on  the  sides  of  the  pelvis.  They  are  oc- 
casionally very  small  in  their  size,  and  the  kidney  on  one 
side  is  sometimes  wanting ;  when  this  is  the  case,  the  size 
of  the  other  kidney  is  larger  than  ordinary. 

It  is  very  difficult  to  assign  a  satisfactory  reason  why 
there  should  be  such  variety  in  the  kidneys;  but  we 'can 
see  that  there  is  little  disadvantage  to  the  animal  functions 
produced  by  this  variety. 

The  kidneys  are  not  large  in  their  size,  and  therefore 
may  be  changed  in  their  situation  without  any  sensible 
inconvenience.  As  their  function  is  independent  of  relative 
situation,  it  must  be  precisely  the  same,  wherever  the 
kidneys  are  placed. 

When  the  kidneys  are  small,  the  secretion  of  the  urine 
may  be  very  nearly  in  the  common  quantity,  from  a  greater 
activity  in  carrying  on  their  function;  or  such  persons 
may  be  disposed  to  sweat  more  than  usual,  to  counter- 

**  Vid.  Lieutaud,  Tom.  I.  p.  282. 
f  See  Medical  communications,  Vol.  I.  p.  416-. 


181 

balance  the  deficiency  of  the  urine.  We  know  very  well 
that  the  secretions  of  the  sweat  and  the  urine  are  vicarious. 
When  a  kidney  is  wanting,  the  other  being  of  a  large  size 
is  probably  capable  of  doing  the  office  of  two  kidneys. 

Diseased  Appearances  of  the  Renal  Capsules. 

The  renal  capsules  are  scarcely  ever  found  diseased. 
The  dark  coloured  substance  in  their  centre,  which  natu- 
rally has  some  consistence,  is  occasionally  very  soft,  so 
as  almost  to  be  fluid.  This  is  probably  what  is  meant  by 
authors,  when  they  say  that  they  have  found  in  the  cavity 
of  the  renal  capsules  a  fluid  like  ink.  Their  description 
may  be  considered  as  being  a  little  exaggerated. 

Abscess  in  the  Renal  Capsules. 

The  renal  capsules  are  very  seldom  attacked  with  in- 
flammation, and  therefore  abscesses  have  very  rarely  oc- 
curred in  them.  There  is  much  variety  in  the  different 
parts  of  the  body,  with  regard  to  their  susceptibility  of 
being  excited  to  inflammation.  A  few  cases  of  abscesses 
in  the  renal  capsules  are  related  by  authors. 

Renal  Capsule  Scrofulous. 

It  has  occurred  to  me  to  see  only  one  instance  of 
scrofula  in  the  renal  capsules.  In  this  case,  the  renal 
capsule  affected  by  it  was  very  much  enlarged  in  its  size, 
being  nearly  as  large  as  a  kidney,  and  was  changed  into 
the  same  kind  of  white  matter,  which  is  observable  in  a 
scrofulous  absorbent  gland. 

The  renal  capsules  have  also  been  observed  to  be  changed 
into  a  cartilaginous  substance,  but  this  morbid  appearance 
occurs  very  rarely.* 

*  See  Dr.  Soemmerring's  German  Translation,  p.  170, 


182 

Little  granules  of  stone  have  been  found  in  the  sub- 
stance of  the  renal  capsules.* 


SYMPTOMS. 

When  the  kidneys  are  inflamed,  more  or  less  pain  is  felt 
in  the  situation  of  these  glands,  and  the  pain  commonly 
shoots  along  the  course  of  the  ureters.  There  is  a  sense 
of  numbness  in  the  thigh,  and  in  the  male  there  is  often  a 
retraction  of  the  testicle,  or  a  feeling  of  pain  in  it.  When 
one  kidney  is  affected,  these  symptoms  are  only  felt  upon 
that  side.  The  urine  is  voided  frequently,  and  is  some- 
times of  a  pale,  but  more  commonly  of  a  deep  red  colour. 
The  stomach  sympathizes  with  this  state  of  the  kidneys, 
for  it  is  affected  with  sickness  and  vomiting :  the  bowels 
are  at  the  same  time  often  costive,  and  subject  to  colicky 
pains.  These  sensations  are  accompanied  with  more  or 
less  of  symptomatic  fever. 

When  pus  is  formed  by  the  progress  of  the  inflamma- 
tion, it  may  be  known  by  its  being  mixed  with  the  urine, 
and  this  will  be  more  distinctly  marked  in  proportion  to 
the  quantity  of  the  pus. 


The  symptoms  which  belong  to  a  scirrhous  state  of  the 
kidneys  are  unknown  to  me,  and  I  do  not  find  that  they 
are  distinctly  marked  by  authors. 

*  Vid.  Lieutaud,  Tom.  I.  p.  286. 


183 

There  would  seem  to  be  no  particular  symptoms  which 
belong  to  the  formation  of  hydatids  in  the  kidneys.  Pain 
is  commonly  felt  in  the  loins  during  their  formation;  there 
has  been  remarked  to  be  symptomatic  fever,  nausea,  and 
vomiting:  but  these  symptoms  belong  also  to  some  other 
diseases.  This  disease,  therefore,  can  only  be  ascertained 
by  hydatids  passing  occasionally  through  the  urethra  along 
with  the  urine.  In  such  cases,  there  must  sometimes  be 
a  difficulty  in  making  water,  from  an  hydatid  interrupting 
the  passage  of  the  urine,  either  at  the  neck  of  the  bladder, 
or  in  some  part  of  the  urethra. 


The  symptoms  which  are  produced  by  calculi  irritating 
the  kidneys  correspond  very  much  with  the  symptoms 
attending  the  inflammation  of  these  organs.  The  irritation 
from  calculi,  however,  may  be  distinguished  from  simple 
imflammation  of  the  kidneys,  by  these  additional  symp* 
toms,  viz.  by  red  crystals  being  often  deposited  from  the 
urine  as  soon  as  it  is  voided,  by  blood  being  sometimes 
mixed  with  the  urine,  and  by  the  pain  of  the  loins  being- 
much  increased  upon  any  jolting  motion  of  the  body. 


Diabetes  is  distinguished  by  the  urine  being  much  in- 
creased beyond  the  natural  quantity,  by  its  being  more  or 
less  sweet  to  the  taste,  and  of  a  colour  somewhat  re- 
sembling  whey.  There  is  great  thirst,  and  often,  although 
not  always,  a  voracious  appetite  for  food.  The  pulse  is 
commonly  not  quicker  than  natural,  and  the  body  becomes 
at  length  much  emaciated. 


184 


CHAPTER  XIV. 


DISEASED   APPEARANCES    OF   THE   BLADDER. 

Inflammation  of  the  Peritoneal  Covering. 

THAT  portion  of  the  peritonaeum,  which  covers  a  part 
of  the  bladder,  is  not  very  often  inflamed  by  itself,  but  it 
partakes  of  the  inflammation  which  extends  over  this 
membrane  generally.  The  appearances  accompanying  its 
inflammation  have  been  already  described.  Inflammation 
of  the  peritonaea!  covering  of  the  bladder  does  not  fre- 
quently extend  to  its  muscular  coat.  The  peritonaeum 
and  the  muscular  coat  of  the  bladder  are  but  loosely  con- 
nected together,  as  a  considerable  quantity  of  cellular 
membrane  is  interposed  between  them.  This  loose  con- 
nection is  necessary,  in  order  that  the  peritonaeum  may  be 
accommodated  to  different  states  of  distention  of  the 
bladder,  and  it  has  also  the  effect  of  preventing  inflamma- 
tion from  spreading  readily  from  the  peritonaea!  covering 
of  the  bladder  to  its  muscular  coat.  When  the  inflam- 
mation subsides,  adhesions  are  frequently  left  behind, 
connecting  the  bladder  more  or  less  to  the  neighbouring 
parts;  in  a  female,  to  the  uterus,  and  in  u  male  to  the 
rectum. 

Inflammation  of  the  inner  Membrane. 

The  inner  membrane  of  the  bladder  is  occasionally  in* 
flamed.  When  this  happens,  the  inflammation  is  some- 
times extended  over  the  whole  cavity,  or  is  sometimes 


185 

confined  to  a  particular  portion  of  it.  The  portion  which 
is  most  frequently  inflamed  is  that  near  the  neck  of  the 
bladder,  This  may  arise  from  two  causes;  the  one  is, 
that  in  this  situation,  or  near  it,  some  obstruction  is  fre- 
quently found  to  the  passage  of  the  urine,  which  may 
produce  irritation,  and  bring  on  more  or  less  of  inflamma- 
tion; the  other  is,  that  inflammations  of  the  urethra  occa- 
sionally extend  some  way  within  the  cavity  of  the  bladder, 
and  even  sometimes  over  the  whole  of  it.  It  is  well 
known  that  the  inner  membrane  of  the  bladder,  in  the 
dead  body,  hardly  shews  vessels  which  are  large  enough 
to  carry  red  blood  in  its  natural  state:  but  when  it  is 
inflamed,  it  is  crowded  with  a  prodigious  number  of  ex- 
tremely fine  blood  vessels,  and  there  may  even  be  some- 
times seen  small  spots  of  extravasated  blood.  When  the 
inflammation  is  in  a  high  degree,  the  muscular  coat  of  the 
bladder  may  be  affected;  but  as  this  is  only  loosely  attached 
to  the  inner  membrane,  the  inflammation  will  not  very 
readily  pass  from  the  one  to  the  other. 

Ulcers. 

Inflammation  of  the  inner  membrane  of  the  bladder 
advances  sometimes  to  the  formation  of  pus,  and  abscesses 
and  ulcers  are  occasionally  produced.  These,  when  the 
inflammation  has  been  of  the  common  sort,  exhibit  the 
ordinary  appearances  which  have  often  been  described. 
They  sometimes  advance  so  far  as  to  destroy  a  portion  of 
the  bladder  entirely,  and  to  form  communications  between 
it  and  the  neighbouring  parts;  as  with  the  general  cavity 
of  the  abdomen,  with  the  rectum  in  the  male,  and  the 
vagina  in  the  female.  When  the  communication  is  formed 
with  the  general  cavity  of  the  abdomen,  the  urine  escapes 


186 

into  it,  producing  there  general  peritonaea!  inflammation, 
of  which  I  recollect  a  very  striking  example.'  When  the 
communication  is  formed  with  the  vagina  or  the  rectum, 
the  urine  will  escape  by  these  passages,  producing  in 
them  more  or  less  of  irritation  and  inflammation. 

When  abscesses  take  place  in  the  bladder,  they  are 
produced  more  frequently  from  local  violence,  than  from 
a  previous  spontaneous  inflammation.  One  of  the  most 
common  causes  of  violence  is  the  incision  of  the  bladder 
in  the  operation  of  lithotomy.  When  the  part  has  been 
very  much  irritated  in  the  operation,  or  the  constitution 
is  such  as  to  be  excited  to  violent  action  by  the  common 
degree  of  irritation,  an  ulcer  is  formed  at  the  lips  of  the 
wound,  and  spreads  more  or  less  into  the  cavity  of  the  bladder. 

It  sometimes  happens,  although  I  believe  very  rarely, 
that  the  whole  of  the  inner  membrane  of  the  bladder  is 
destroyed  by  ulceration,  and  its  muscular  fibres  appear  as 
bare  as  if  they  had  been  nicely  dissected.  In  the  case 
where  I  recollect  this  process  to  have  taken  place  most 
completely,  the  bladder,  was  almost  filled  with  a  scrofulous 
pus.  There  was  a  curdly  white  matter  mixed  with  pus, 
Xvhich  had  exactly  the  same  appearance  with  that  formed 
by  the  suppuration  of  a  scrofulous  absorbent  gland. 

Scirrhus  and  Cancer. 

From  the  contiguity  of  the  bladder  to  parts  which  are 
very  liable  to  scirrhus  or  cancer,  it  sometimes  partakes  of 
this  disease  ;  but  I  do  not  think  that  it  is  often  separately 
affected  by  it.  The  disease  on  some  occasions  spreads  to 
the  bladder  from  the  rectum,  and  on  others  from  the  uterus; 
under  such  circumstances  the  bladder  becomes  very  thick 
and  hard,  and  exhibits  the  ordinary  cancerous  structure. 


187 

Communications  too  are  generally  formed  either  with  the 
rectum,  the  uterus,  or  the  vagina. 

I  believe,  however,  that  the  bladder  has  sometimes  been 
independently  affected  with  scirrhus  and  cancer,  and  that 
scirrhous  tumours  have  been  formed  in  its  cavity,  but,  as  I 
have  stated  above,  these  morbid  appearances  are  very  rare.* 

Fungous  Excrescences. 

Sometimes  fungous  excrescences  arise  from  the  inner 
surface  of  the  bladder,  either  in  one  mass,  or  in  separate 
portions.  Upon  examination  they  are  found  to  consist  of 
a  loose  fibrous  structure.  When  they  are  situated  a  little 
behind  the  neck  of  the  bladder,  which  is  not  uncommonly 
the  case,  they  must  produce  a  considerable  obstruction  to 
the  passage  of  the  urine.  A  stronger  action  will,  therefore, 
be  required  in  the  bladder  to  expel  the  urine,  and  its  mus- 
cular coat  will  be  consequently  thickened.  Accordingly 
it  is  often  found  thickened  in  these  cases,  and  it  is  not 
improbable  that  even  where  the  situation  of  the  fungus 
may  not  obstruct  the  passage  of  the  urine  into  the  urethra, 
its  presence  may  still  irritate  the  bladder,  so  as  to  excite 
it  to  more  frequent  and  stronger  actions  than  in  a  natural 
state,  and  the  muscular  coat  may  become  thereby  more  or 
less  thickened. 

Polypus  of  the  Bladder. 

A  polypus  sometimes  grows  from  the  inner  surface  of 
ihe  bladder;  but  this  morbid  appearance  occurs  very 
rarely.  I  have  only  seen  one  example  of  it,  and  in  this 
instance  it  filled  up  the  greater  part  of  the  cavity  of  the 
bladder.  It  was  very  irregular  in  its  shape,  consisting  of 

*  Vid.  Portal's  Anatomic  Medicale,  Tom.  V.  p.  409  and  410, 


188 

various  projecting  masses,  and  seemed  pretty  firm  in  its 
texture. 

Elongations  of  the  inner  Membrane. 

I  have  also  known  the  inner  membrane  of  the  bladder 
elongated  in  some  parts,  so  as  to  form  irregular  processes. 
These  when  cut  into,  were  found  to  consist  of  a  consid- 
erable quantity  of  cellular  membrane,  intermixed  with  a 
little  fat.  The  process  producing  such  an  appearance  was 
probably  a  slow  one,  and  was  probably  also  not  attended 
with  pain.  If  these  elongations  were  to  be  situated  at  a 
distance  from  the  neck  of  the  bladder,  they  would  probably 
not  produce  any  inconvenience ;  but  if  situated  near  the 
neck  of  the  bladder,  they  might  occasion  extreme  difficulty 
in  making  water,  and  even  lay  the  foundation  of  a  fatal 
disease. 

Veins  of  the  inner  Membrane  of  the  Bladder  enlarged^ 
and  varicose. 

Some  instances  have  occurred  in  which  the  veins  of  the 
inner  membrane  of  the  bladder  have  become  enlarged  and 
varicose,  similar  to  the  enlargement  of  the  veins  of  the 
lower  part  of  the  rectum,  in  piles.  This  will  be  most  apt 
to  happen  were  there  has  been  a  considerable  impediment 
to  the  return  of  the  blood  by  the  veins  of  the  bladder,  as 
in  cases  where  the  absorbent  glands,  upon  the  sides  of  the 
cavity  of  the  pelvis,  have  become  much  enlarged,  or  where 
any  tumour  has  been  formed  within  the  pelvis,  which  has 
a  good  deal  compressed  these  veins,* 

*  Vid.  Portal's  Anatomic  Medicale,  Tom.  V.  p.  411 


,189 


Cysts  communicating  'with  the  bladder. 

Cysts  are  sometimes  found  connected  very  intimately 
with  the  bladder,  and  communicating  with  its  cavity. 
These  in  some  instances  have  been  observed  to  be  of  a 
large  size,  being  perhaps  half  as  large  as  the  usual  size  of 
the  bladder  itself.  There  is  some  difficulty  in  explaining 
the  manner  in  which  they  are  formed.  If  we  suppose 
them  to  be  formed  in  the  cellular  membrane,  upon  the 
outside  of  the  bladder,  it  is  extremely  difficult  to  explain 
how  they  should  communicate  with  its  cavity,  unless  by 
ulceration,  which  does  not  take  place.  If  we  suppose 
them  to  be  pouches  from  the  bladder  itself,  it  is  still  diffi- 
cult, in  some  instances,  to  explain  why  they  should  be 
formed  at  all,  and  why  they  should  arrive  at  so  large  a  size. 
The  latter  supposition,  however,  seems  to  be  the  most 
reasonable  and  I  am  persuaded  it  will  apply  to  the  greater 
number  of  cases  where  such  cysts  exist. 

Muscular  Coat  thickened. 

One  of  the  most  ordinary  changes  in  the  bladder,  from 
its  natural  structure,  is  the  great  thickening  of  its  muscular 
coat.  In  a  natural  state,  the  muscular  coat  of  the  bladder 
(when  it  is  moderately  distended)  consists  of  thin  layers 
of  muscular  fibres,  running  in  different  directions.  These 
are  probably,  altogether,  not  more  than  the  eighth  of  an 
inch  in  thickness.  The  muscular  coat  of  the  bladder, 
however,  is  occasionally  found  at  least  half  an  inch  thick. 
This  arises  from  an  additional  quantity  of  muscle  being 
formed  in  consequence  of  extraordinary  efforts  being 
necessary  in  the  bladder.  These  efforts  take  place  when 
there  is  any  considerable  difficulty  in  making  water,  as 


190 

happens  when  the  prostate  gland  is  a  good  deal  enlarged, 
when  there  is  a  stone  in  the  bladder,  or  when  there  are 
strictures  in  the  urethra.  It  is  usual,  therefore,  to  find 
this  thickening  of  the  muscular  coat  of  the  bladder  when 
there  is  any  of  these  diseases.  When  the  bladder  is 
thickened,  the  fasciculi  of  which  its  muscular  coat  is  com- 
posed become  much  larger ;  but  never,  or  at  least  very 
seldom,  acquire  the  full  red  colour  which  muscles  of  the 
same  size  have  in  other  parts  of  the  body.  This  is  a  de- 
viation from  the  general  plan  of  nature  with  regard  to  the 
increase  of  muscles  from  exercise.  When  muscles  are 
enlarged  in  size  from  exercise,  they  also  become  of  a  deep 
red  colour.  There  is  no  other  instance  in  the  body,  as 
far  as  I  recollect,  of  a  muscle  being  so  much  enlarged 
beyond  its  natural  size,  in  consequence  of  increased  exer- 
tion, as  the  muscular  coat  of  the  bladder. 

Between  the  fasciculi  of  the  muscular  fibres,  little 
pouches  are  formed  by  the  inner  membrane.  This  arises 
from  the  pressure  of  the  urine  against  the  inner  membrane 
of  the  bladder,  which  is  impelled  by  the  strong  powers  of 
the  muscular  coat.  These  pouches  are  often  large  enough 
to  admit  the  end  of  the  finger,  and  contain  occasionally 
small  calculi.  The  bladder  in  this  state  admits  of  very 
little  distention,  so  that  it  is  capable  of  containing  little 
\vater:  hence  the  inclination  to  make  water  is  frequent, 
and  frequent  efforts  of  the  muscular  coat  are  required, 
which  increase  more  and  more  its  thickness.  It  is  much 
more  common  to  find  this  appearance  of  the  bladder  in  the 
male  than  in  the  female,  because  in  the  latter  there  are 
fewer  causes  to  produce  it :  since  in  that  sex  there  is  a 
want  of  the  prostate  gland  altogether,  and  the  urethra  being 
short  and  wide,  obstructions  seldom  take  place  in  it.  When 


191 

the  muscular  coat  of  the  bladder  has  been  thickened,  I 
believe  that  it  has  been  sometimes  mistaken  for  scirrhus. 

The  Bladder  divided  into  two  Chambers. 

The  urinary  bladder  has  sometimes  been  observed  to 
be  divided  into  two  chambers,  which  communicate  with 
each  other;  but  this  has  happened  very  rarely.  I  have 
not  had  an  opportunity  myself  of  examining  this  singular 
disease,  but  I  have  received  an  account  of  such  a  case 
from  Dr.  Ash,  which  had  many  years  ago  fallen  under  his 
observation.  The  upper  chamber  of  the  bladder  in  this 
case  was  generally  much  distended  with  urine,  so  that  a 
round  tumour  could  be  easily  distinguished  by  the  touch 
above  the  pubes.  When  a  catheter  was  introduced  into 
the  bladder,  a  few  ounces  only  of  urine  came  away,  and 
the  tumour  above  the  pubes  remained  the  same  as  before. 
When  the  patient  stood  up,  a  quart  of  water  sometimes 
passed  away  involuntarily,  the  tumour  very  much  subsided, 
and  the  complaint  was  relieved  for  the  time.  After  the 
death  of  the  patient,  the  bladder  was  found  upon  examina- 
tion to  be  divided  into  two  chambers  by  a  firm  membra- 
nous substance,  and  the  aperture  of  communication  was 
almost  obliterated. 

There  seem  to  me  to  be  only  two  ways  in  which  a 
division  of  the  bladder  into  two  chambers  can  happen. 
The  one  is  by  a  morbid  growth  of  the  inner  membrane, 
forming  a  ridge  at  some  particular  part,  and  at  length  by1 
a  continuation  of  this  process,  making  a  septum  more  or 
less  complete  in  the  bladder  I  have  seen  the  cavity  of 
the  sesophagus  very  much  narrowed  at  one  part  by  a 
permanent  ridge  being  formed  in  its  inner  membrane. 
Something  of  the  same  kind  I  have  also  seen  in  a  parf 


192 

of  the  small  intestines.  We  may  therefore  readily  admit 
the  possibility  of  a  similar  process  taking  place  in  the 
inner  membrane  of  the  bladder. 

Another  way  in  which  the  bladder  may  be  supposed 
capable  of  being  divided  into  two  chambers,  is  by  a  very 
strong  contraction  of  its  transverse  muscular  fibres  at 
some  particular  part.  This  will  be  analogous  to  the  hour- 
glass contraction  of  the  uterus,  which  is  known  occasion, 
ally  to  take  place.  When  a  complaint  of  the  bladder 
depending  upon  its  being  divided  into  two  chambers  has 
been  temporary,  it  is  reasonable  to  suppose  that  it  has 
arisen  from  the  last  cause;  when  it  has  been  permanent 
it  is  more  likely  to  have  arisen  from  the  first. 

Calculi. 

Calculi  are  not  uncommonly  found  in  the  bladder,  and 
are  confined  in  their  formation  to  no  particular  period  of 
of  life.  They  are  formed  in  very  young  chilclren,  and 
also  in  persons  of  middle  and  advanced  age.  This  disease 
is  nut  so  frequently  met  with  in  the  female  as  in  the  male, 
which  may  depend  on  two  causes;  the  one  is,  that  there 
is  not  so  strong  a  tendency  to  their  formation  in  that  sex ; 
and  the  other  cause  is,  that  stones  escape  through  the 
urethra  in  women,  which  would  be  detained  in  the  bladder 
of  men,  and  lay  the  foundation  there  of  larger  calculi. 

The  stones  which  are  found  in  the  bladder,  are  either 
originally  formed  in  the  kidneys,  and  pass  through  the 
ureters  into  the  bladder,  or  they  are  first  formed  in  the 
bladder  itself.  When  the  latter  circumstance  takes  place? 
the  earthy  matter  is  sometimes  first  deposited  round  some 
extraneous  body,  which  becomes  the  nucleus  of  the 
calculus,  but  most  frequently  no  nucleus,  whatever  is  to 


193 

be  observed.  The  nuclei  which  I  have  seen,  have  been 
small  portions  off  lead  (probably  broken  of  from  a  leaden 
bougie)  small  nails,  and  little  masses  of  hair.  In  short, 
any  extraneous  body  which  may  happen  to  be  introduced 
into  the  bladder,  may  become  a  nucleus.  It  is  natural  to 
think  that  such  nuclei  are  more  common  in  the  calculi 
found  in  the  bladder  of  women  than  of  men,  because  their 
urethra  is  wider  and  shorter,  so  that  an  extraneou  s  body 
can  be  much  more  easily  introduced  into  their  bladder. 

The  calculi  of  the  bladder  either  lie  loose  in  it,  or  are 
confined  to  some  fixed  situation  from  particular  circum- 
stances. When  they  are  of  a  small  size,  they  are  sometimes 
lodged  in  pouches,  or  sacculi,  formed  by  the  protrusion 
of  the  inner  membrane  of  the  bladder  between  the  fasciculi 
of  its  muscular  fibres.  A  calculus  also  is  occasionally 
attached  to  an  excrescence  of  the  bladder,  so  as  to  be  kept 
in  a  fixed  situation. 

There  is  frequently  one  calculus  only  in  the  bladder  at 
a  time,  and  then  it  is  usually  of  an  oval  form ;  but  there 
are  often  more,  and  the  calculi  by  rubbing  upon  each 
other  in  a  narrow  space  acquire  flat  sides  and  angles. 
Calculi  have  sometimes  a  smooth  uniform  surface  but  most 
frequently  the  surface  is  granulated.  These  granules  arc 
commonly  placed  very  near  each  other  over  the  whole 
surface  of  the  calculus,  giving  it  a  certain  degree  of  roughness. 
They  are,  however,  occasionally  gathered  into  clusters  on 
particular  parts  of  the  surface  of  a  calculus.  These  granules 
are  sometimes  of  a  smaller  and  sometimes  of  a  larger  size, 
and  in  different  calculi  are  more  or  less  elevated.  Some 
calculi  have  an  irregular  porous  structure  upon  the  sur- 
face, instead  of  being  granulated. 

Calculi  when  divided  by  the  saw,  or  broken,  exhibit 


194 

most  coitimonly  a  laminated  structure.  These  laminae 
are  disposed  in  concentric  curves,  and  are  applied  together 
with  more  or  less  compactness:  in  some  calculi  the  laminae 
adhere  together  very  slightly.  They  differ  in  their  thick- " 
ness  in  different  calculi :  and  the  laminated  structure 
sometimes  pervades  uniformly  the  whole  mass  of  the 
calculus ;  while  at  other  times  different  portions  of  it  are 
interrupted  by  a  coarse  porous  texture.  In  some  calculi 
no  laminated  structure  whatever  is  observable,  but  it  is 
entirely  porous. 

The  colour  of  calculi  varies  considerably.  They  are 
most  frequently  of  a  brown  colour,  which  is  sometimes 
of  a  lighter  and  sometimes  of  a  darker  shade.  They  are 
also  sometimes  of  a  white,  and  often  of  a  yellowish  colour. 
It  is  remarkable,  that  different  portions  of  the  same  calculus 
are  frequently  of  a  different  colour.  Some  laminae,  for 
instance,  are  perfectly  white,  while  the  other  laminae  are 
brown.  In  this  sort  of  mixture,  I  have  most  commonly 
found  the  white  laminae  on  the  outside,  and  the  brown 
laminae  in  the  middle;  but  this  distribution  probably 
varies  in  different  calculi. 

The  specific  gravity  of  urinary  calculi  differs  very  con- 
siderably, as  they  differ  a  good  deal  in  their  compactness ; 
but  they  are  in  general  nearly  twice  the  specific  gravity 
of  water. 

It  is  only  within  a  few  years  that  the  chemical  analysis 
of  urinary  calculi  has  been  ascertained  with  sufficient 
accuracy,  and  they  have  been  found  to  consist  of  seven 
species  very  different  from  each  other. 

The  first  species  is  more  common  than  the  others,  and 
consists  of  a  particular  acid  called  lithic  acid,  mixed  with 
some  gelatinous  matter,  and  in  some  instances  with  a 


195 

very  small  proportion  of  lime.  Its  texture  is  partly  lam- 
inated and  partly  porous.  Its  colour  is  brown,  varying 
a  good  deal  in  the  depth  of  its  shade,  and  sometimes  with 
a  very  slight  yellowish  tinge.  The  chemical  properties 
of  this  species  of  urinary  calculi  were  first  ascertained  by 
Scheele  and  Bergman. 

The  second  species  is  the  triple  phosphat,  which  consists 
of  the  union  of  phosphoric  acid  with  magnesia  and  ammo- 
nia It  has  externally  a  sparkling  crystalline  appearance,  and 
hardly  ever  occurs  in  a  pure  state;  but  this  triple  salt 
often  enters  into  a  composition  of  other  calculi,  and  more 
especially  into  that,  which  is  called  the  fusible  calculus.* 

The  third  species  consists  of  crystals  which  are  formed 
by  the  combination  of  phosphoric  acid  with  magnesia  and 
ammonia :  these  are  mixed  with  some  phosphorated  lime, 
and  generally  with  some  lithic  acid.  It  is  of  a  white  colour, 
is  more  irregular  in  its  shape  than  some  of  the  other 
species  and  consists  partly  of  a  laminated  and  partly  of  a 
porous  structure,  It  is  fusible  by  the  blow-pipe,  and 
therefore  has  commonly  been  called  the  fusible  calculus. 

The  fourth  species  consists  of  the  acid  of  sugar 
and  acid  of  phosphorus  united  with  lime;  together 
generally  with  some  lithic  acid  in  the  interstices.  This 
species  is  knotted  on  its  outer  surface  somewhat  like 
a  mulberry,  and  from  this  circumstance  it  has  commonly 
been  called  the  mulberry  calculus.  It  is  of  a  dark  brown 
colour,  and  consists  of  an  irregularly  laminated  structure. 
The  lamina?  of  which  it  is  composed  often  vary  in  their 
colour,  some  of  them  being  dark,  and  others  of  a  white 
colour.  The  white  laminae  are  commonly  towards  the 
outer  part  of  the  calculus,  although  its  colour  be  dark, 

*  See  Dr.  Marcel's  excellent  Essay  upon  Calculcus  Disorders, 


196 

The  fifth  species  consists  entirely  of  phosphorated  lime, 
and  has  been  called  the  bone-earth  calculus.  It  is  of  a 
light  brown  colour,  and  its  laminae  slightly  adhere  to  each 
other.  For  an  accurate  analysis  of  these  three  last  species 
of  urinary  calculi,  we  are  chiefly  indebted  to  Dr.  Wm. 
Hyde  Wollaston. 

The  sixth  species  consists  of  carbonat  of  lime,  mixed 
with  a  little  animal  matter  and  water,  and  was  discovered 
lately  by  Mr.  Crumpton.* 

A  seventh  species  of  calculus  has  lately  been  discovered 
by  Dr.  Win.  Hyde  Wollaston.  He  has  only  met  with 
two  instances  of  it,  and  therefore  it  must  be  considered  as 
being  very  rare.  It  resembles  the  calculus  containing 
the  triple  phosphate  of  magnesia:  its  substance  is  not 
distinctly  laminated,  but  rather  appears  like  a  mass  con- 
fusedly crystallized.  This  species  of  calculus  readily 
unites  with  acids  and  alkalies,  contains  a  small  proportion 
of  oxygen,  and  appears  to  be  an  oxyd  of  a  peculiar  kind. 
Dr.  Wollaston  has  given  it  the  name  of  the  cystic  oxyd.f 

Not  unfrequently  a  calculus  shall  consist  of  some 
of  the  different  species  above  described,  arranged  in 
alternate  strata :  and  sometimes  it  shall  consist  of  the  in- 
gredients of  different  species  of  calculi  combined  together 
without,  or  with  very  little  distinct  appearances  of  stratifi- 

cation.J 

The  matter  of  calculus  in  the  bladder  is  generally  formed 
into  one  or  more  circumscribed  masses,  yet  it  sometimes 
happens  that  the  whole  bladder  is  filled  with  a  substance 
like  mortar.  Of  this  I  recollect  one  striking  example ; 

*  See  Thompson's  System    of  Chemistry,  Vol.  4,  page  671. 

jSec  Philosophical  Transactions,  Part  2.  1810. 

tSee  Dr.  Marcel's  Essay  upon  Calculous  Disorders,  p,  88  and  90. 


197 

the  earthy  matter  in  this  case  could  not  be  entirely  removed 
from  the  bladder,  but  a  great  many  small  irregular  portions 
still  adhered  to  the  sides  of  its  cavity.  Within  the  last 
three  years  I  have  met  with  another  instance  in  which  the 
matter  of  calculus  put  on  the  appearance  and  consistence 
of  mortar,  but  was  in  small  quantity.  It  was  connected 
with  a  chronic  inflammation  of -the  inner  membrane  of  the 
bladder,  and  processes  of  coagulable  lymph  attached  to 
the  inner  membrane  were  encrusted  with  the  calculous 
matter.  This  disease  had  continued  for  many  years,  and 
was  combined  with  stricture  of  the  urethra. 

Bladder  distended. 

In  opening  dead  bodies,  the  bladder  is  occasionally 
found  to  be  very  much  distended,  and  to  occupy  the 
lower  part  of  the  cavity  of  the  abdomen.  This  might 
arise  from  some  accidental  circumstance  of  the  water  being 
accumulated,  while  the  muscular  coat  of  the  bladder  still 
possessed  its  proper  powers ;  or  the  muscular  coat  of  the 
bladder  may  have  been  paralytic,  and  therefore  not  capable 
of  expelling  the  water.  1  do  not  think  it  is  possible  to 
discriminate  between  these  two  different  cases  by  any 
examination  after  daath,  but  they  can  always  be  ascertained 
by  a  careful  inquiry  into  their  history. 

Bladder  contracted. 

The  bladder  is  also  found  contracted  to  such  a  degree 
as  hardly  to  have  any  cavity.  This  is  sometimes  not  to 
be  considered  as  a  disease,  but  simply  as  having  arisen 
from  a  very  strong  action  of  the  muscular  coat  of  the 
bladder  previously  to  death. 

Not  unfrequently  when  the  inner  membrane  of  the 


198 

bladder  has  been  long  in  an  irritable  state,  the  muscular 
part  of  it  from  the  habit  of  contracting  upon  small  quanti- 
ties of  urine,  looses  the  power  of  being  distended,  and 
remains  more  or  less  permanently  contracted. 

The  anterior  Part  of  the  Bladder  wanting. 

The  anterior  part  of  the  bladder  is  occasionally  wanting, 
and  instead  of  it  there  is  a  very  soft  vascular  flesh,  situated 
externally  at  the  lower  part  of  the  abdomen.  This  soft 
vascular  flesh  is  usually  formed  into  irregular  projecting 
masses,  and  in  the  living  body  is  covered  with  a  thick 
ropy  mucus.  The  two  ureters  open  somewhere  upon 
this  vascular  flesh,  distilling  gradually  the  urine  upon  its 
surface,  which  the  mucus  is  intended  to  protect  against 
the  stimulus  of  that  fluid.  When  there  is  such  a  forma- 
tion of  the  bladder,  I  believe  that  there  is  always  a  de- 
ficiency of  the  bone  at  the  symphysis  pubis,  and  also  a 
monstrous  formation  of  some  of  the  organs  of  generation. 
This  species  of  monstrosity  I  have  described  at  large  in 
the  Medical  and  Chirurgical  Transactions.* 

77ze  Bladder  and  the  Rectum  communicating  from 
original  Malformation. 

Another  kind  of  monstrous  formation  in  the  bladder 
occasionally  happens,  viz.  that  at  its  depending  part  there 
is  a  communication  between  it  and  the  rectum,  the  latter 
being  continued  into  the  former.  Of  this  I  have  seen  one 
instance;  and  it  has  been  already  taken  notice  of,  when 
treating  of  the  diseased  and  preternatural  appearances  of 
the  intestines. 

*  See  Medical  and  Chirurgical  Transactions,  Vol.  I.  p.  189. 


199 


Hernia  of  the  Bladder. 

The  bladder,  or  a  portion  of  it,  has  been  known  to 
protrude  as  a  hernia  through  the  abdominal  ring,  or  under 
Paupart's  ligament.  As  the  anterior  part  of  the  bladder, 
which  has  no  peritonaea!  covering,  protrudes  first,  the 
hernia  is  not  contained  in  a  hernial  sack.  If  the  hernia 
be  large,  the  bladder  drags  down  a  portion  of  peritonaeum, 
forming  a  true  hernial  sack  above  it,  but  still  the  bladder 
is  on  the  outside  of  the  sack.* 


SYMPTOMS. 

•  In  inflammation  of  the  bladder,  a  pain  is  felt  in  the 
perinseum,  or  above  the  pubes,  accompanied  with  a 
fullness  or  a  swelling  there.  There  are  frequent  attempts 
to  make  water,  which  is  evacuated  in  small  quantity  and 
with  great  pain;  or  there  is  a  total  retention  of  the  urine, 
with  a  strong  desire  to  void  it.  The  rectum  is  affected 
from  its  connection  with  the  bladder,  and  is  excited  to 
tenesmus.  The  stomach  likewise  takes  a  part  in  the 
disease,  and  is  affected  with  sickness  and  vomiting.  In 
some  cases  there  is  delirium.  When  pus  has  been  formed 
in  consequence  of  the  inflammation,  it  is  known  by  being 
mixed  with  the  urine  which  is  evacuated. 

When  the  bladder   has  become  affected  by  an  ulcer 
spreading  to  it  from  the  neighbouring  parts,  it  may  be 

suspected   by  the   pain   and  difficulty  which   occur   in 

i 

*  See  Pott  oi\  Ruptures,  p.  226. 


making  water.  When  the  ulcer  has  made  further  progress, 
and  a  communication  has  thereby  taken  place  between  the 
bladder  and  the  uterus,  or  between  the  bladder  and  the 
vagina,  or  between  the  bladder  and  the  rectum,  it  may  be 
distinguished  by  the  urine  passing  either  through  the 
vagina  or  the  anus,  attended  with  pain  and  irritation;  or 
by  air,  or  by  feculent  matter  occasionally  passing  through 
the  urethra. 


When  two  chambers  are  just  beginning  to  be  formed 
in  the  bladder,  very  little  inconvenience  is  probably  felt, 
because  the  communication  between  them  at  this  time 
is  very  large.  Under  such  circumstances  it  seems  hardly 
possible  to  detect  the  nature  of  the  disease  in  the  living 
body;  but  when  the  disease  has  made  a  considerable 
progress,  and  the  communication  between  the  two 
chambers  has  become  very  narrow,  it  may  be  ascertained, 
or  at  least  conjectured  about  with  great  probability,  from 
the  following  circumstances.  There  will  then  be  a  con- 
siderable circumscribed  tumour  above  the  pubes  in  the 
situation  of  the  bladder  when  distended,  much  less  urine 
will  be  made  than  the  natural  quantity,  and  the  tumour 
will  not  be  sensibly  lessened  by  it;  or  if  a  catheter  be 
introduced,  little  urine  will  be  evacuated,  and  the  tumour 
above  the  pubes  will  still  remain  the  same.  But  it  will 
occasionally  happen,  by  some  particular  attitude  of  the 
body,  that  the  urine  will  pass  from  the  upper  chamber  of 
the  bladder  ii)to  the  lower,  and  from  this  it  will  be 
evacuated  by  the  urethra;  under  such  circumstances  there 
will  be  a  much  larger  quantity  of  urine  made  than  usuaL 


201 

the  tumour  above  the  pubes  will  disappear,  and  the  patient 
will  receive  immediate  relief,  which  will  continue  till  there 
is  another  accumulation  of  urine. 


The  existence  of  fungous  excrescences  from  the  inner 
surface  of  the  bladder  may  probably  be  ascertained  in  some 
instances  during  life  by  the  introduction  of  a  catheter,  but 
in  general  we  cannot  be  certain  of  the  real  nature  of  the 
disease  till  the  parts  are  examined  after  death*  When  the 
excrescence  is  situated  near  the  neck  of  the  bladder,  there 
will  be  more  or  less  difficulty  of  voiding  the  urine.  In 
other  instances  the  patient  makes  water  at  short  intervals; 
and  often  feels  the  desire,  and  strains  in  order  to  make 
water  when  there  is  little  or  none  in  the  bladder.  The 
urine  is  frequently  tinged  with  blood.  But  these  symp- 
toms are  common  to  this  and  other  diseases,  and  the 
symptoms  alone  do  not  therefore  furnish  us  with  any 
certain  marks  by  which  the  disease  may  be  distinguished. 


The  symptoms  which  belong  to  a  polypus  formed  in  the 
bladder  are  unknown  to  me;  but  they  are  probably  much 
the  same  with  those  which  attend  fungous  excrescences 
in  the  bladder. 


The  symptoms  which  attend  calculi  in  the  bladder  are 
well  known.  There  is  an  uneasy  sensation  at  the  orifice  of 
2C 


202 

the  urethra  after  making  water,  or  after  exercise.  When 
the  calculus  is  large,  a  dull  pain  is  generally  felt  at  the 
neck  of  the  bladder.  The  attempts  to  tnake  water  are 
frequent,  and  it  often  passes  drop  by  drop,  or  the  stream 
is  suddenly  interrupted.  The  urine  deposits  a  large  pro- 
portion of  a  mucous  sediment,  which  is  produced  by  the 
mucous  glands  at  the  neck  of  the  bladder  being  irritated 
by  the  calculus  to  an  increased  secretion.  The  urine  is 
also  occasionally  tinged  with  blood,  from  some  small  blood 
vessels  being  ruptured  by  a  rough  part  of  the  stone,  and 
this  is  most  apt  to  happen  after  some  jolting  motion. 
There  is  tenesmusj  in  consequence  of  the  connection  of 
the  rectum  with  the  bladder,  and  the  sympathy  which  has 
been  established  between  their  respective  functions. 

When  the  calculous  matter  is  soft,  resembling  mortar, 
there  is  great  pain  and  difficulty  in  making  water,  which 
is  voided  frequently,  and  in  small  quantity ;  portions  of 
this  matter  are  occasionally  discharged,  along  with  the 
urine,  and  generally  mixed  with  a  ropy  mucus  tinged 
with  blood. 


203 


CHAPTER  XV. 

DISEASED    APPEARANCES    OF    THE    VESICULjE 

SEMINALES. 

THE  diseased  appearances  of  the  vesiculse  seminales 
are  but  little  known,  because  from  their  situation  these 
bodies  cannot  be  seen  without  a  good  deal  of  dissection ; 
whereas  many  of  the  viscera  come  immediately  into  view, 
when  the  cavity  in  which  they  are  lodged  is  simply  laid 
open :  diseased  appearances,  however,  have  been  occasion- 
ally observed  in  the  vesiculse  seminales. 
• 

Vesiculte  Seminales  inflamed. 

It  has  never  occurred  to  me  to  observe  the  vesicular 
seminales  inflamed  by  themselves,  although  they  are,  doubt- 
less, liable  to  this  disease,  like  other  parts  of  the  body. 
I  have  seen  them,  however,  involved  in  the  natural  conse- 
quences of  inflammation  with  the  surrounding  parts. 
Thus  I  have  seen  the  posterior  surface  of  the  bladdre, 
the  vesiculse  seminales,  and  a  portion  of  the  rectum  ad- 
hereing  with  unusual  firmness  together,  in  the  same  manner 
as  other  parts  of  the  body  do  after  inflammation.  Some 
few  instances,  however,  have  occurred,  in  which  so  great 
an  inflammation  had  been  e^xcited  in  the  vesiculse  seminales$ 
as  to  terminate  in  suppuration.* 

*  See  Dr.  Soemm.erring's  German  Translation,  p.  194r 


204 


Vesiculae  Seminales  scrofulous. 

The  vesiculae  seminales  are  also  affected  with  scrofula. 
I  recollect  to  have  seen  one  of  the  vesiculse  seminales 
filled  with  true  scrofulous  matter,  the  distinguishing  cha- 
racteristic of  which  has  been  often  mentioned. 

Ducts  of  the  Vesicults  Seminales  terminating  in  a  Cul-de-sac. 

The  ducts  ofthe  vesciulae  seminales  open  naturally  by  two 
distinct  orifices  into  the  cavity  of  the  prostate  gland,  but 
they  are  occasionally  wanting,  and  the  vesiculae  seminales 
terminate  in  a  cul-de-sac.  The  vasa  differentia  are  at  the 
same  time  without  their  natural  termination,  for  they  end 
in  the  cul-de-sac  of  the  vesiculae  seminales.  This  is  a 
species  of  monstrosity  which  is  very  rare,  but  it  is  of  great 
consequence,  because  it  prevents  the  semen  from  passing 
into  the  urethra,  and  frustrates  one  of  the  most  important 
functions  in  the  animal  economy.  An  instance  of  this 
sort  of  malformation  is  preserved  in  Dr.  Hunter's  collection. 


Seminales  very  small. 

The  vesiculae  seminales  differ  a  good  deal  in  their  size 
in  different  adult  bodies,  and  indeed  it  is  very  common  for 
the  one  to  be  considerably  smaller  than  the  other;  but  I 
have  oftener  than  once  seen  both  of  them  so  small  that  they 
must  have  been  very  little  able  to  fulfil  the  intentions  for 
which  they  were  formed. 

One  ofthe  Vesiculte  Seminales  wanting. 

One  of  the  vesiculae  seminales  is  occasionally  wanting 
altogether.  Under  such  circumstances  I  believe  that  the 
extremity  of  the  vas  deferens  upon  that  side  is  generally 


205 

enlarged  and  tortuous,  becoming  a  sort  of  substitute  for 
it.  This  was  at  least  the  case  in  the  instance  which  I 
have  seen  of  this  mode  of  formation.  The  extremity  of 
the  vas  deferens  has  at  all  times  a  structure  similar  to  that 
of  the  vesicular  seminales,  and  renders  therefore  this  con- 
jecture  very  probable. 


Seminales  scirrhous. 

The  vesicular  seminales  have  also  been  observed  to  be 
scirrhous;  but  this  is  very  uncommon,*' 


Small  stones  have  also  been  seen  in  the  vesiculae  sem- 
inales, but  they  have  not  fallen  under  my  own  observation ; 
and  they  are  of  very  rare  occurrance.f 


SYMPTOMS. 

The  symptoms  which  attend  diseases  of  the  vesiculce 
seminales,  have  not  been  attempted  to  be  discriminated 
by  authors,  and  must,  from  circumstances,  be  very  difficult 
to  ascertain.  It  has  only  occurred  to  myself  to  observe 
some  diseased  changes  of  them  in  the  dead  body;  and  I 
have  had  no  opportunity  of  tracing  the  symptoms  which 
accompany  these  changes  during  life. 

*  See  Morgagni,  fipist.  XL VI.  Art.  5. 

•••  See  Soemmerring's  Germ.  Translat.  p.  193. 


206 


CHAPTER  XVI. 

DISEASED   APPEARANCES    OF   THE   PROSTATE    GL 

Abscess  in  the  Prostate  Gland. 

THE  prostate  gland  is  not  often  found  in  a  state  of 
common  Inflammation.  I  have  seen,  however,  an  abscess 
in  it,  without  any  uncommon  thickening  and  enlargement 
of  the  gland,  and  where-  the  pus  appeared  to  be  of  the 
common  sort.  This  must  be  considered  as  being  a 
common  abscess,  and  must  have  been  preceded  by  the 
ordinary  sort  of  inflammation. 

Scrofula  of  the  Prostate  Gland. 

The  prostate  gland  is  sometimes  scrofulous.  I  have 
seen,  in  cutting  into  it,  precisely  the  same  white  curdly 
matter,  which  is  formed  in  a  scrofulous  absorbent  gland. 
In  squeezing  it  also,  I  have  forced  out  from  its  ducts  a 
scrofulous  pus. 

Scirrhus  of  the  Prostate  Gland. 

The  most  common  disease  of  the  prostate  gland  is  a 
scirrhous  enlargement  of  it.  The  prostate,  gland,  it  is 
well  known,  is  naturally  about  the  size  of  a  large  chesnut, 
but  when  it  is  affected  with  scirrhus,  it  is  often  enlarged  to 
the  size  of  the  fist.  In  this  enlarged  state,  when  cut  into, 
it  exhibits  a  very  solid,  whitish,  or  brown  substance,  with 
membranous  septa  running  through  it  in  various  directions, 
which  are, often  very  strongly  marked.  This  is  the  com- 
mon appearance  of  scirrhus  in  other  parts  of  the  body. 


207 

When  the  prostate   gland  is  a  good  deal  enlarged, 
cavity  becomes  deeper  from  the  growth  of  its  sides,  and 
the  posterior  extremity  forms  a  considerable   projection 
into  the  cavity  of  the  bladder,  which  interrupts  the  passage 
of  the  urine  into  the  urethra.*     According  to  the  degree 
of  this  projection,  the  urine  is  passed  with  greater  or  less 
difficulty,    as   well   as  an  instrument  for  drawing  it  off. 
When  the  projection  is  very  great,  it  has  sometimes  been 
found  impossible  to  pass  an  instrument  over  the  projection, 
and  an  artificial  passage  has  been  made  through  it  acci- 
dentally, by  which  the  urine  has  been  evacuated.     Under 
such  circumstances  the  gland  has  been  known  not  to  be 
irritated  by  the  violence  used  in  making  this  new  passage, 
and  life  has  been  prolonged  for  a  greater  length  of  time 
than  it  would  have  been  otherwise.     Still,  however,  the 
instrument  ought  to  be  made  to  pass  over  the  projection, 
if  possible;  and  we  should  never  run  the  risk,  by  injuring 
the  gland,  of  bringing  on  immediately  fatal  consequences. 
Sometimes  in   the   progress    of  the   enlargement   the 
prostate  gland  grows  irregularly,  and  a  winding  passage 
is  formed  through  it,  by  an  alteration  in  the  shape  of  its 
cavity.     This  increases  the  difficulty  to  the  patient  of 
making  water,  and  to  the  surgeon  of  introducing  an  in- 
strument.     When    the   prostate  gland   is   enlarged,    its 
internal  surface  is  sometimes  ulcerated,  but  commonly  it 
is  not.-f    Fistulous  communications  are  sometimes  formed 

*  Sir  Everard  Home  has  lately  discovered  that  this  posterior  projection  is 
owing  to  the  enlargement  of  a  small  separate  lobule  of  the  prostate  gland,  not 
hitherto  known. 

|  Although  I  hav.e  given  the  name  of  scirrhus  to  this  affection  of  the  prostate 
gland  from  its  hardness,  and  the  similarity  of  its  structure  to  that  of  scirrhus 
in  some  other  glands,  yet  it  would  seem  to  be  essentially  different  from  it 
This  disease  has  little  or  no  disposition  to  run  into  ulceration,  and  it  is  capabl.- 
of  subsiding,  which  would  not  be  the  case  if  it  were  a  true  scirrhus. 


208 

between  an  enlarged  prostate  gland  and  the  rectum.  Both 
of  these  effects  are  generally  produced  by  an  uncautious 
introduction  of  catheters  or  bougies. 

It  is  obvious  too,  from  what  has  been  mentioned,  that 
in  an  enlarged  state  of  the  prostate  gland,  the  'difficulty  of 
making  water  must  be  very  great.  This  difficulty  excites 
extraordinary  and  very  frequent  efforts  in  the  bladder  to 
overcome  it.  Its  muscular  coat  becomes  consequently 
much  stronger  and  thicker,  than  in  the  natural  state.  A 
prostate  gland  therefore,  is  never  found  enlarged  to  any 
considerable  degree,  without  the  bladder  having  undergone 
this  change  in  its  muscular  coat.  This  disease  is  hardly 
ever  to  be  found  in  a  young  person,  but  is  not  at  all  un- 
common at  an  advanced  period  of  life. 

Calculi  in  the  Ducts  of  the  Prostate  Gland. 

There  is  another  disease  of  the  prostate  gland,  which 
occasionally  takes  place,  although  it  is  by  no  means  so 
frequent  as  the  former,  viz.  a  formation  of  small  calculi, 
which  are  lodged  in  its  ducts.  They  are  usually  of  the 
size  of  a  small  pea,  and  those  which  I  have  seen  have  been 
of  a  brown  colour,  which  is  lighter  or  darker  in  its  shade. 
They  have  been  found  by  Dr.  Wm.  Hyde  Wollaston  to 
consist  of  phosphorated  lime  in  the  state  of  neutralization. 

Ducts  of  the  Prostate  Gland  enlarged. 

The  prostate  gland  is  sometimes  seen  with  its  cavity 
very  much  widened,  and  its  ducts  enlarged.  In  the 
natural  state  of  the  gland,  the  orifices  of  its  ducts  can 
hardly  be  seen,  but  they  sometimes  are  so  much  enlarged, 
as  to  be  capable  of  admitting  a  crow  quill.  When  the 
ducts  are  so  enlarged,  there  is  always  a  great  obstruction 


209 

.4o  the  passage  of  the  urine  through  the  urethra,  arising 
most  commonly  from  stricture  there.  The  urine,  either 
passing  in  very  small  quantity,  or  being  entirely  prevented 
from  passing,  is  accumulated  in  the  cavity  of  the  prostate 
gland  and  the  bladder.  The  effect  of  this  accumulation 
is,  that  the  cavity  of  the  prostate  gland  is  widened,  and 
the  ducts  very  much  enlarged.  The  bladder  too,  from 
making  extraordinary  efforts  to  overcome  the  obstruction % 
has  its  muscular  coat  gradually  thickened,  and  often  to  a 
very  considerable  degree.  Attending,  therefore,  this  state 
of  the  prostate  gland  there  is  a  thickened  bladder,  and 
an  obstructed  urethra. 

The  Prostate  Gland  pretcrnaturally  small. 

I  have  also  seen  the  prostate  gland  of  an  extremely 
small  size,  so  that  it  could  hardly  be  considered  as  being 
fit  for  its  office.  It  was  attended  with  a  monstrous  for- 
mation of  the  urinary  bladder  and  some  of  the  organs  of 
generation,  and  has  been  particularly  described  by  me  in 
the  Medical  and  Chirurgical  Transactions.* 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  of  the  pros- 
tate gland  have  been  little  taken  notice  of  by  authors.  It 
is  reasonable  to  think,  that  there  will  be  a  sense  of  paia 
more  or  less  acute  at  the  neck  of  the  bladder,  with  much 
difficulty  in  making  water,  or  a  complete  obstruction  to 

*See  page  194,  Vol.  I. 

2D 


210 

this  evacuation,  and  probably  tenesmus.  This  disease 
may  be  distinguished  from  a  scirrhous  enlargement  of 
the  prostate  gland,  by  its  quick  progress,  and  by  the 
pain  which  is  felt  in  it. 


When  the  prostate  gland  is  affected  with  scrofula,  little 
inconvenience  is  probably  felt  at  an  early  state  of  the 
complaint;  but  if  the  gland  should  increase  very  consid- 
erably in  its  size,  those  symptoms  must  necessarily  arise 
which  depend  upon  its  enlargement,  and  which  are  just 
about  to  be  mentioned. 


When  the  prostate  gland  becomes  enlarged  from 
bcirrhus,  there  is  a  difficulty  in  voiding  the  urine,  and 
a  small  quantity  only  is  discharged  at  a  time,  so  that 
the  bladder  is  kept  always  nearly  full.  There  is  some- 
times a  total  inability  to  evacuate  the  urine.  In  some 
cases  the  fasces  are  passed  with  difficulty,  and  when  the 
operation  is  over,  there  is  still  a  feeling  of  something 
more  to  be  discharged.  The  straining  which  attends  the 
evacuation  of  the  urine  and  the  fasces  not  unfrequently 
forces  out  mucus,  which  has  been  secreted  by  the  gland. 
A  bougie  or  catheter  is  either  passed  into  the  bladder 
with  difficulty,  or  on  some  occasions  is  not  capable  of 
toeing  passed  at  all. 


Calculi  occur  so  rarely  in  the  prostate  gland,  that  their 
symptoms  have  been  little  taken  notice  of  by  authors. 
When  the  calculi  are  very  small,  so  as  to  be  confined 
entirely  within  the  ducts  of  the  prostate  gland,  it  is  prob- 
able that  little  inconvenience  is  produced  by  them.  When 
they  are  larger,  and  form  a  projection  into  the  cavity  of 
the  prostate  gland,  there  must  necessarily  be  difficulty  in 
voiding  the  urine,  and  there  will  be  the  same  feeling 
when  a  sound  or  catheter  is  attempted  to  be  passed  into 
the  bladder,  as  if  an  urinary  calculus  had  got  fixed  or 
impacted  into  the  neck  of  the  bladder. 


CHAPTER  XVIL 


DISEASED   APPEARANCES    OF   THE   URETHRA. 

Abscesses. 

ABSCESSES  are  occasionally  formed  in  the  membranous 
part  of  the  urethra.  These  may  arise  from  an  inflam- 
mation, produced  by  some  latent  cause,  as  abscesses  are 
formed  in  any  other  part  of  the  body;  but  they  happen 
most  frequently  from  an  obstruction  to  the  passage  of 
urine  through  the  urethra.  This  obstruction  is  produced 
generally  by  a  stricture  in  some  part  of  this  canal,  and 
most  frequently  it  is  at  or  near  the  bulb  of  the  corpus 
spongiosum  urethrae.  The  urine  being  forced  by  the 
efforts  of  the  bladder  behind  the  stricture,  irritates  that 
part,  producing  inflammation  and  suppuration ;  the  abscess 
breaks  externally,  and  the  urine  is  evacuated  by  this 
opening. 

Fistula. 

While  the  obstruction  in  the  urethra  continues,  the 
opening  made  by  the  breaking  of  the  abscess  is  not  dis- 
posed to  heal  up,  but  a  fistulous  orifice  is  gradually  form- 
ed.  This  is  surrounded  with  parts  somewhat  thickened 
and  hard,  as  fistulse  are  generally.  The  most  common 
situation  for  these  fistulous  openings  is  behind  the  scrotum, 
because  the  most  common  situation  of  the  stricture  is/ 
at  or  near  the  bulb  of  the  corpus  spongiosum  urethrae. 
Not  uncommonly  there  are  more  tha»  one  of  these 


213 

openings,  leading  to  short  canals  which  run  in  different 
directions. 

Stone  in  the  Cavity  of  the  membranous  Part  of  the  Urethra. 

The  cavity  of  the  membranous  part  of  the  urethra  I 
have  seen  distended  into  a  bag  large  enough  to  contain  a 
hen's  egg.  This  bag  was  occasioned  by  a  large  stone 
having  lodged  there.  The  stone  had  probably  been 
driven  intp  the  cavity  of  the  membranous  part  of  the 
urethra,  by  the  stream  of  urine  from  the  bladder,  but  was 
too  large  to  pass  by  the  same  means  through  the  whole 
length  of  the  urethra;  it  therefore  stuck  in  that  situation, 
and  was  gradually  increased  to  the  size  which  we  have 
described,  by  the  contact  of  the  urine,  similar  to  the 
growth  of  a  stone  in  the  pelvis  of  the  ureters. 

Cjotvper's  Glands  seldom  observed  to  be  diseased. 

I  d#;  not  recollect  to  have  seen  Cowper's  glands 
diseased,  which  are  situated  near  this  part  of  the  urethra. 
They  are  doubtless  liable  to  changes  from  disease,  like 
other  parts  of  the  body ;  but  they  are  small  and  difficult 
of  access,  so  that  they  have  very  seldom  become  an  object 
of  examination. 

Morgagni  mentions  one  of  them  being  converted  into 
a  ligamentous  substance;*  and  the  excretory  duct  of  one 
in  another  instance  being  obliterated.! 

Inner  Membrane  of  the  Urethra  inflamed. 

The  inner  membrane  of  the  urethra  is  very  liable  to  be 
inflamed,  particularly  at  its  anterior  extremity,  and  the 

*  See  Morgagni,  Epist.  XLIV.  Art.  3. 
|  See  Morgagni,  Epist.  XUY.  Art.  12, 


214 

inflammation  occasionally  spreads  over  the  whole  extent 
of  the  canal.  This  exhibits  no  appearance  different  from 
the  inflammation  of  membranes  lining  secretory  canals 
which  open  externally.  The  membrane  is  much  more 
crowded  with  small  blood  vessels  than  in  a  natural  state, 
and  there  is  an  increased  secretion  of  the  glands  which 
open  upon  it.  The  inflammation  is  often  not  confined  to 
the  inner  membrane  of  the  urethra,  but  spreads  into  the 
substance  of  the  corpus  spongiosum,  affecting  both  its 
cellular  structure  and  its  glands.  Under  these  circum- 
stances the  corpus  spongiosum  is  enlarged  and  harder 
from  the  extravasation  of  the  coagulable  lymph  into  its 
cells,  and  is  more  vascular  than  in  a  natural  state.  The 
glands  being  increased  in  size  from  the  inflammation, 
become  sensible  to  the  touch,  like  very  small  rounded 
tubercles. 

Ulcers  in  the  Urethra. 

Ulcers  are  also  seen  occasionally  in  laying  open  the 
Urethra,  but  these  are  not  frequent.  This  canal  when 
inflamed  has  little  disposition  to  ulcerate,  as  happens  also 
to  some  other  canals  in  the  body,  as  for  example  the 
trachea. 

Stricture. 

The  most  ordinary  diseased  appearance  of  the  urethra 
is  stricture.  This  consists  in  a  part  of  the  canal  being 
narrowed,  or  perhaps  altogether  obliterated.  It  may  take 
place  in  any  part  of  the  canal,  but  it  is  most  frequent  at  or 
near  the  bulb  of  the  corpus  spongiosum  urethrae.  This 
stricture  sometimes  consists  simply  of  an  approximation 
of  the  opposite  sides  of  the  canal,  so  as  to  form  a  line  of 


215 

obstruction;  at  other  times  the  canal  is  narrowed  for  sonfe 
length.  The  inner  membrane  at  the  stricture,  sometimes 
exhibits  the  natural  appearance;  sometimes  it  is  a  little 
thickened,  and  occasionally  its  surface  is  abraded  or 
ulcerated.  These  two  last  effects  are  generally  produced 
by  bougies;  and  sometimes  false  passages  have  been  made 
into  the  corpus  spongiosum  urethrse,  in  consequence  of 
employing  too  much  violence  in  the  use  of  this  instrument. 
There  is  often  more  than  one  stricture  in  the  same  urethra. 
It  sometimes  happens  too  that  the  stricture  is  more  on  one 
side  of  the  canal  than  the  other,  so  that  the  passage  there 
is  crooked. 

Caruncle. 

A  small  fleshy  excrescence  sometimes  grows  in  the 
.urethra.  This  is  called  a  caruncle,  and  used  formerly  to 
be  considered  as  the  most  common  ca.use  of  obstruction 
in  this  canal;  but  since  dissections  of  dead  bodies  have 
become  more  frequent,  it  has  been  found  in  reality  to  be 
very  rare. 

Enlargement  of  the  Mucous  Glands  of  the  Urethra. 

Not  unfrequently  one  of  the  small  mucous  glands  of  the 
urethra  becomes  enlarged  and  hard  from  inflammation, 
making  a  tumour  of  the  size  of  a  pea,  or  bigger,  which 
projects  towards  the  canal  of  the  urethra,  and  narrows  its 
diameter.  This  is  usually  the  consequence  of  gonorrhoea, 
but  it  may  arise  from  inflammation  brought  on  by  the 
improper  use  of  bougies,  or  in  any  other  way.  < 

A  layer  of  earthy  Matter  in  the  Urethra. 
I  have  known  one  instance  of  a  thin  laver  of  earthv 


216  * 

matter  extending  from  the  bladder  through  the  whole 
Jength  of  the  urethra. 

Preternatural  Orifice  of  the  Urethra. 

The  urethra  sometimes  does  not  open  at  the  projecting 
extremity  of  the  glans  penis,  but  under  it,  where  the 
the  frasnum  is  naturally  situated;  and  in  such  cases  there 
is  no  fraenum.  It  consists  of  a  small  rounded  opening, 
much  less  than  the  natural  termination  in  the  glans.  I 
have  known  an  instance  in  this  structure  of  parts,  of  a 
canal  being  formed  besides  the  urethra,  about  two  inches 
in  length,  which  terminated  at  one  extremity  in  a  cul-de- 
sac,  and  at  the  other  opened  on  the  glans,  where  the 
urethra  commonly  does.  How  far  this  variety  may  be 
frequent,  I  cannot  pretend  to  determine.  This  deviation 
in  the  structure  is  not  to  be  considered  as  a  disease,  but 
simply  as  a  malformation  of  parts,  and  is  not  attended  with 
any  material  inconvenience,  as  far  as  I  know. 

There  are  some  other  diseased  appearances  of  the  penis, 
such  as  ulcers,  phymoses,  paraphymoses,  &c.  These  are 
external,  are  much  more  commonly  met  with  in  the  living, 
than  Jn  the  dead  body,  and  are  very  well  known;  I  shall 
therefore  omit  them  entirely. 


SYMPTOMS. 

The  symptoms  which  attend  the  inflammation  of  the 
inner  membrane  of  the  urethra,  are  too  well  known  to 
require  being  mentioned. 


217 


In  stricture  of  the  urethra  there  is  difficulty  in  making 
water,  which  is  greater  or  less  according  to  the  degree  of 
the  stricture;  the  stream  of  urine  is  small,  sometimes 
forked,  sometimes  scattered,  and  sometimes  the  urine 
passes  away  in  drops  only.  There  is  frequently  also  an 
increased  secretion  of  mucus  from  the  urethra,  resembling 
a  gleet.  Various  other  symptoms  may  take  place,  in 
consequence  of  the  parts  in  the  neighbourhood  of  the 
stricture  being  affected;  and  even  the  constitution  is 
sometimes  much  disturbed  by  this  local  irritation,  ex- 
hibiting very  different  symptoms  in  different  individuals. 


When  the  urethra  is  obstructed  by  the  growth  of  a 
caruncle,  no  symptoms  are  known  by  which  it  may  be 
distinguished  from  a  case  of  common  stricture. 


CHAPTER  XVIII. 


DISEASED   APPEARANCES    OP   THE   TESTICLES,   AN/> 
THE    SPERMATIC  CHORD. 

Hydrocele. 

HYDROCELE,  or  a  collection  of  water  in  the  tunica 
vaginalis  testis,  is  a  very  common  disease,  and  is  confined 
to  no  particular  period  of  life.  It  is  not  unfrequent  in  very 
young  children,  and  in  them,  most  commonly  disappears 
without  any  chirurgical  treatment.  The  bag  in  which  the 
water  is  accumulated  is  of  a  pyramidical  shape,  and 
approaches  more  or  less  towards  the  ring  of  the  abdominal 
muscle,  according  to  the  degree  of  accumulation.  It  some- 
times extends  almost  to  the  ring  itself.  The  bag  is  also 
more  or  less  thick  in  different  cases :  it  is  often  scarcely 
thicker  than  the  tunica  vaginalis  in  its  natural  state  ;  some- 
times, when  the  accumulation  is  large,  it  is  three  or  four 
times  as  thick,  and  is  obviously  laminated.  In  such  cases 
too  the  testicle  is  a  good  deal  compressed,  and  has  some- 
times been  known  to  waste  in  consequence  of  this  com- 
pression. The  fluid  which  is  accumulated  is  of  a  yellow- 
ish, a  greenish,  or  brown  colour,  and  resembles  in  its 
properties  the  serum  of  the  blood.  This  disease,  in  persons 
who  are  advanced  in  life,  is  sometimes  combined  with  a 
scirrhous  state  of  the  testicle,  which  will  be  afterwards 
particularly  described. 

In  almost  all  cases  of  hydroccle  the  water  is  contained 
in  one  bag,  but  in  a  few  instancea  it  has  been  known  to 


219 

be  contained  in  several  cysts.  Of  this  I  recollect  a  re- 
markable example  which  occurred  a  few  years  ago.  This 
variety  is  probably  produced  by  repeated  partial  inflamma- 
tions on  the  inner  surface  of  the  tunica  vaginalis,  and 
occasioning  adhesions,  which  put  on  the  appearance 
of  cysts. 

Hydatids. 

Hydatids  have  sometimes  been  found  in  the  cavity  of 
the  tunica  vaginalis  testis,  either  loose  or  adhering;  they 
are,  I  believe,  not  very  uncommon,  but  I  have  had  no 
favourable  opportunity  of  examining  them  accurately. 

Loose  Cartilages  in  the  Tunica  Vaginalis  Testis* 

Small  cartilages  are  sometimes  found  loose  in  the  cavity 
of  the  tunica  vaginalis  testis,  as  in  some  of  the  joints  in 
the  body,  more  especially  the  knee  joint.  They  do  not 
however  occur  in  the  former  so  frequently  as  in  the  latter. 
They  must  once  have  been  attached  to  some  part  of  the 
inner  surface  of  the  tunica  vaginalis  testis,  by  very  small 
processes  or  peduncles,  and  by  the  motion  of  this  tunic 
upon  the  testicle  they  must  have  been  separated.  They 
afterwards  continue  to  lie  loose  in  the  cavity  of  the  tunica 
vaginalis  testis,  and  are,  I  believe,  attended  with  no  in- 
convenience. An  example  of  this  kind  has  been  seen  by 
myself,  and  it  has  not  unfrequently  been  observed  by 
others. 

Adhesions. 

The  tunica  vaginalis  is  frequently  found  adhering  to  the 
surface  of  the  testicle.  The  adhesion  is  sometimes  ex- 
tended over  the  whole  surface,  but  frequently  consists 


220 

only  of  scattered  processes  of  membrane.  The  adhesions 
are  sometimes  fine,  but  sometimes  they  have  considerable 
thickness,  and  connect  the  tunica  vaginalis  to  the  body 
of  the  testicle  more  or  less  closely  in  different  cases.  They 
are  produced  by  some  previous  inflammation  in  the 
tunica  vaginalis  testis,  as  adhesions  are  formed  after  in- 
flammation in  the  cavity  of  the  chest,  or  the  belly. 

Testicle  inflamed. 

The  substance  of  the  testicle  itself  is  frequently  in- 
flamed, but  this  disease  is  commonly  removed  by  art, 
and  hardly  ever  becomes  an  object  of  examination  after 
death.  It  exhibits,  however,  precisely  the  same  ap- 
pearances as  the  inflammation  of  the  substance  of  other 
parts,  and  therefore  does  not  require  to  be  particularly 
described.  When  the  testicle  is  inflamed,  the  vas  de- 
ferens  sometimes  partakes  of  the  inflammation,  its  coats 
becoming  considerably  thickened,  and  in  some  instances 
the  veins  of  the  spermatic  chord  becoming  varicose.* 
After  the  inflammation  of  the  testicle  has  subsided,  it  is 
not  unusual  for  a  hardness  and  fullness  of  the  epididymis 
to  remain  for  a  considerable  length  of  time,  or  even 
through  life.  This  depends  on  the  matter  which  had 
been  extravasated  during  the  inflammation,  not  being 
afterwards  entirely  absorbed. 

Abscesses  of  the  Testicle. 

Abscesses  too  are  occasionally  formed  in  the  testicles, 
from  the  progress  of  common  inflammation,  and  are 
attended  with  the  same  circumstances  as  abscesses  in 
other  parts. 

*  See  Mr,  Hunter  on  the  Veneral  Disease,  p.  54, 


221 


Testicle  scrofulous. 

The  testicle  is  sometimes  completely  changed  from  its 
natural  structure,  and  converted  into  a  truly  scrofulous 
mass.  Upon  such  occasions  it  is  generally  enlarged,  and 
when  cut  into  shews  a  white,  or  yellowish-white,  curdly 
substance,  which  is  sometimes  more  or  less  mixed  with  pus. 

Testicle  enlarged  and  pulpy. 

The  testicle  is  sometimes  much  enlarged,  and  converted 
into  an  uniform,  pulpy  matter,  in  which  its  natural  struc- 
ture is  entirely  lost.  This  sort  of  change  has  been  some- 
times mistaken  for  scirrhus,  but  it  is  very  different  from 
what  is  called  scirrhus  in  other  parts  of  the  body,  and 
what  is  also  found  in  the  testicle  itself. 

Scirrhus  and  Cancer  of  the  Testicle. 

The  testicle  is  also  found  much  enlarged,  and  changed 
into  a  hard  mass,  which  is  generally  more  or  less  intersec- 
ted by  membranes.  In  this  there  is  no  vestige  of  the 
natural  structure,  but  cells  are  frequently  observable  in 
it  containing  a  sanious  fluid,  and  sometimes  there  is  a 
mixture  of  cartilage.  This  state  of  the  testicle  I  consider 
as  the  true  scirrhus,  and  according  to  the  progress  of  the 
disease,  the  epidydimis  and  the  spermatic  chord  are  more 
or  less,  or  not  at  all,  affected.  This  disease  not  unfre- 
quently  advances  to  form  a  foul  deep  ulcer  with  thickened 
edges,  or  throws  out  a  fungus,  and  then  it  is  called  the 
true  cancer  of  the  testicle. 

Testicle  cartilaginous* 
The  testicle  I  have  seen  much  enlarged  and  changed 


222 

into  a  mass  of  cartilage.  There  was  also  in  the  case  to 
which  I  allude,  an  ulcer  near  the  centre  of  the  cartilage, 
and  in  some  places  an  imperfect  appearance  of  cysts,  or 
cells.  The  cartilage  did  not  seem  different  in  any  essential 
property  from  common  cartilage,  but  was  a  little  softer. 
This  I  consider  as  depending  upon  the  same  general 
diseased  process  with  the  scirrhus  just  described,  for 
sometimes  both  structures  are  blended  together  in  the 
same  testicle. 

Testicle  bony. 

.  The  testicle  is  sometimes  converted  into  bone.  A 
few  instances  only  of  this  disease  have  fallen  under  my 
observation,  and  in  them  the  bony  process  had  not  exten- 
ded over  the  whole  substance  of  the  testicle,  but  had 
affected  it  partially. 

A  Cyst  adhering  to  a  Testicle  containing  a  Vena  Medinensis. 

I  have  seen  a  testicle  with  a  small  firm  cyst  adhering 
to  it,  which  contained  a  worm  of  that  sort  called  vena 
medinensis.  This  is  a  worm  of  considerable  length,  with 
a  smooth  surface  and  an  uniform  appearance ;  at  the  pos- 
terior extremity  it  terminates  in  a  slender  hook-like  process, 
and  at  the  anterior  there  is  a  rounded  opening  or  mouth. 
This  testicle  had  probably  belonged  to  a  man  who  had 
visited  some  of  those  climates  in  which  the  vena  medinen- 
sis is  found,  and  who  had  brought  it  over  with  him  to 
this  country. 

The  Epididymis  ending  in  a  Cul-de-sac. 

The  testicles  have  sometimes  this  sort  of  mal-formation, 
that  the  epididymis  does  not  terminate  in  a  vas  deferens, 


223 

but  in  a  cul-de-sac.  In  these  cases  it  is  evident  that  the 
semen  cannot  be  evacuated  by  the  urethra,  and  that  the 
person  must  therefore  be  incapable  of  procreation.  In 
Dr.  Hunter's  collection,  a  preparation  of  this  sort  is  pre- 
served ;  and  Mr.  Hunter  has  given  a  representation  of 
it  in  his  book  upon  the  Animal  Economy.* 

Stricture  of  the  Fas  Defer  ens. 

I  have  also  seen  a  portion  of  the  canal  of  the  vas  deferens 
obliterated  by  stricture.  This  had  not  been  an  original 
fault,  but  was  the  effect  of  a  diseased  process,  similar, 
probably,  to  that  which  produces  stricture  in  the  urethra, 
and  must  have  prevented  the  semen  of  one  of  the  testicles 
from  reaching  the  cavity  of  the  prostate  gland. 

Testicles  very  small,  and  wasted 

The  testicles  are  sometimes  exceedingly  small  in  their 
size.  I  have  known  one  case,  in  a  person  of  middle  age, 
where  each  of  them  was  not  larger  than  the  extremity  of 
the  finger  of  an  adult.  This,  as  appeared  from  its  history, 
arose  from  a  fault  in  the  original  formation,  and  was 
attended  with  a  total  want  of  the  natural  propensities.  It 
is  much  more  common  for  a  testicle  to  waste  either 
spontaneously,  or  in  consequence  of  a  previous  inflam- 
mation, or  compression,  so  as  gradually  to  disappear 
entirely,  f 

Sometimes  one  testicle,  and  sometimes  both,  remain 
in  the  cavity  of  the  abdomen  through  life,  so  that  a  person 
appears  to  have  only  one  testicle,  or  to  be  without  them 
altogether.  The  testicle  or  testicles,  I  believe,  are  in 

*  See  page  47,  plate  V. 
t  See  Hunter  on  the  Venereal  Disease*  p,  209. 


224 

these  cases  of  a  small  size;  and  Mr.  Hunter  suspects  that 
they  are  by  no  means  so  perfect,  as  when  they  descend 
into  the  scrotum.* 

Diseased  Appearances  of  the  Spermatic  Chord.  Spermatic 
Chord  Scirrhous. 

The  spermatic  chord  is  also  liable  to  diseased  alterations 
of  structure ;  one  of  the  most  common  is  that  of  its  be- 
coming scirrhous.  This  I  believe  to  be  very  rarely,  if  at 
all,  an  original  disease  of  the  chord,  but  always,  or 
almost  always  spreads  to  it  from  the  testicle.  In  the 
early  state  of  a  scirrhous  testicle  the  spermatic  chord  is 
perfectly  sound;  but  when  the  disease  has  existed  for  a 
considerable  time,  and  does  not  remain  stationary,  the 
chord  becomes  at  length  affected.  Under  such  circum- 
stances it  is  changed  into  a  hard  mass,  exhibiting  the  same 
appearance  of  structure  as  the  testicle  itself.  During  the 
last  stage  the  disease  advances  to  the  loins,  so  as  to  affect 
the  absorbent  glands  there. 

Feins  of  the  Spermatic  Chord  varicose. 

A  disease  of  the  spermatic  chord  which  is  not  uncommon, 
is  an  enlargement  of  its  veins.  The  veins  of  the  spermatic 
chord  are  numerous,  and  support  a  very  long  column  of 
blood.  This  last  circumstance,  added  to  some  impedi- 
ments which  occasionally  take  place  to  the  return  of  the 
blood,  renders  the  veins  frequently  enlarged.  This 
enlargement  varies  very  much  in  different  cases,  arising 
from  the  degree  and  the  continuance  of  the  impediment. 
When  the  enlargement  of  the  veins  is  very  considerable, 
they  also  become  varicose,  and  the  spermatic  chord  is 

*  See  Mr.  Hunter's  Observations  on  certain  parts  of  the  Animal  Econo- 
my,  p,  18. 


225 

changed  into  a  bulky  mass,  soft  to  the  feeling,  and  capable 
of  being  readily  diminished  upon  pressure.  In  this  state 
of  the  spermatic  chord,  the  testicle  is  sometimes  wasted. 

Water  accumulated  in    the    Cellular  Membrane   of  the 
Spermatic  Chord. 

Water  has  sometimes  been  known  to  be  accumulated  in 
the  cells  of  the  cellular  membrane,  which  envelopes  the 
vessels  of  the  spermatic  chord.  The  cellular  membrane 
of  this  part  of  the  body  is  in  considerable  quantity,  and 
when  water  is  accumulated  in  its  cells,  a  large  swelling  is 
formed  in  the  situation  of  the  spermatic  chord,  which  is 
readily  diminished  upon  pressure.  When  pressure  is 
used,  the  swelling  is  diminished,  not  only  by  a  part  of 
the  water  being  forced  into  the  cells  of  the  chord  within 
the  abdominal  ring,  but  also  by  its  being  forced  into  the 
cellular  membrane  under  the  skin  of  the  lower  part  of  the 
belly.  Many  pints  have  been  known  to  be  accumulated 
in  these  cells.  It  has  never  occurred  to  myself  to  see 
this  disease,  and  therefore  I  have  had  no  opportunity  of 
examining  the  nature  of  the  fluid;  but  I  presume  it  is  of 
the  same  sort  with  what  is  usually  found  in  anasarca. 

A  Sack  containing  Water  formed  in  the  Spermatic  Chord. 

A  sack  has  also  been  known  to  be  formed  in  the  sper- 
matic chord,  consisting  of  a  firm  white  membrane,  and 
containing  a  fluid,  which  most  probably  is  of  a  serous 
nature.  Both  of  these  cases  have  been  particularly  tie- 
scribed  by  Mr.  Pott,  in  his  treatise  upon  Hydrocele.* 

*  For  the  first  case,  See  Pott  on  Hydrocele,  p,  39.    For  the  second,  see 
Pott  on  Hydrocele,  p.  57. 

2F 


226 


SYMPTOMS. 


The  existence  of  hydrocele  in  the  living  body,  may  be 
determined  by  the  shape  of  the  tumour,  which  is  in  some 
degree  pyramidal,  by  the  resistance  which  it  gives  upon 
pressure,  by  want  of  pain  in  it,  and  by  the  health  being 
not  affected  by  it.  Where  the  tunica  vaginalis  is  thin, 
and  the  swelling  is  placed  between  the  eye  and  a  lighted 
candle,  in  will  appear  transparent.  Where  the  tunica 
vaginalis,  however,  is  thick,  the  transparency  will  be  lost, 
and  the  tumour  to  the  feeling  will  be  harder,  and  less 
compressible.  But  still  it  will  not  have  the  same  degree 
of  hardness  as  a  scirrhous  testicle,  and  will  want  some 
other  characteristic  marks  which  belong  to  the  latter 
disease. 


The  formation  of  hydatids  in  the  tunica  vaginalis  testis 
is  attended  with  symptoms  which  correspond  very  much 
with  those  of  hydrocele ;  and  this  case  can  only  be  distinctly 
known  by  laying  open  the  sack. 


An  inflamed  testicle  may  be  distinguised  from  a  scirrhous 
one  in  the  living  body,  by  a  slight  attention  to  the  appear- 
ances, and  to  the  history  of  the  case.  The  progress  of 
the  disease,  in  an  inflamed  testicle,  is  commonly  rapid, 
and  the  skin  of  the  scrotum  immediately  covering  it  has 


227 

usually  a  blush  of  inflammation ;  but  in  a  scirrhous  testicle, 
the  progress  of  the  disease  is  slow,  and  the  skin  of  the 
scrotum  retains  its  natural  colour,  unless  it  be  really 
affected  by  the  disease.  The  surface  of  the  tumour  in 
an  inflamed  testicle  is  uniform  and  smooth,  but  in  a  scirr- 
hous testicle  is  often  irregular. 


When  a  testicle  is  scrofulous  or  pulpy,  it  may  be  dis- 
tinguished from  a  scirrhous  testicle  by  its  greater  softness, 
by  the  little  pain  which  is  felt  in  it,  and  by  the  absence 
of  some  symptoms  which  generally  attend  scirrhus  of 
this  gland,  and  which  are  just  about  to  be  mentioned. 


A  scirrhous  testicle  may  be  ascertained  in  the  living 
body  by  its  great  hardness,  and  by  the  pain  that  is  often 
felt  in  it,  which  darts  along  the  spermatic  chord  to  the 
loins.  Its  progress  is  commonly  slow,  the  spermatic 
chord  becomes  ultimately  diseased,  and  the  general  health 
at  length  much  impaired.  When  it  throws  out  a  fungus, 
or  forms  an  ill-conditioned  ulcer,  these  become  additional 
external  marks  of  the  nature  of  the  disease. 


The  encysted  tumour  of  the  spermatic  chord,  containing 
water,  resembles,  in  some  appearances,  hydrocele.  It 
may,  however,  be  distinguished  from  it  by  the  testicle 
being  felt  separate  and  entire  under  the  tumour,  which  m 
hvdrocele  is  never  the  case. 


±28 


CHAPTER  XIX. 


3>lSEASED    APPEARANCES    IN    THE    FEMALE    ORGANS, 

Inflammation  of  the  Uterus. 

WHEN  the  uterus  becomes  inflamed,  it  takes  place 
almost  always  under  the  same  circumstances,  viz.  very 
soon  after  parturition.  The  inflammation  is  sometimes 
confined  to  the  uterus  itself,  or  its  appendages,  but  the 
peritonaeum  in  the  neighbourhood  is  most  commonly 
affected,  and  frequently  over  its  whole  extent.  The 
uterus  when  inflamed,  exhibits  the  same  appearances  as 
the  inflammation  of  the  substance  of  other  parts,  and  these 
are  principally  observable  in  its  body  or  fundus.  The 
inflammation  is  frequently  found  to  creep  along  the  ap- 
pendages of  the  uterus,  especially  the  Fallopian  tubes  and 
ovaria.  It  often  advances  to  suppuration,  and  the  pus  is 
generally  found  in  the  large  veins  of  the  womb.*  When 
the  peritoneeum  is  also  afiected  by  inflammation,  it  exhibits 
the  same  appearances  which  we  formerly  described,  when 
treating  of  the  inflammation  of  this  membrane ;  but  the 
extravasated  fluid,  and  the  coagulable  lymph,  are  frequently 
in  a  large  proportion  to  the  degree  of  the  inflammation.! 

Malignant  Ulcer  of  the  Uterus. 
It  is  not  unusual  for  an  ulcer  to  be  formed  in  the  uterus, 

•  See  Dr.  Clark's  Essays,  p.  69  and  70. 

|  Dr.  Clarke,  who  has  examined  a  great  many  women  that  have  died  after 
parturition  with  inflammation  of  the  peritonseum,  has  observed  this  particularly. 
See  Dr.  Clarke's  Essays,  p.  136. 


229 

of  a  very  malignant  nature.  This  is  most  apt  to  happen 
in  women  at  the  middle  period  of  life,  or  at  a  more  ad- 
vanced age;  but  it  sometimes  happens  in  women  who 
may  still  be  said  to  be  young-  The  ulcer  generally  begins 
in  the  cervix  uteri,  and  the  uterus  is  at  the  same  time 
somewhat  harder  and  larger  than  in  the  natural  state.  It 
does  not,  however,  grow  to  any  considerable  size.  The 
ulcer  spreads  from  the  cervix  to  the  fundus  uteri,  and 
it  is  not  unusual  to  see  the  greater  part  of  the  fundus 
destroyed-  by  it,  the  rest  being  changed  into  a  tattered 
ulcerated  mass.  The  ulceration  is  not  always  confined 
in  its  boundaries  to  the  uterus,  but  sometimes  spreads 
into  the  neighbouring  parts,  as  the  vagina,  the  bladder, 
and  the  rectum,  making  communications  between  them, 
and  producing  dreadful  havock.  This  disease  of  the 
uterus  is  generally  considered  as  cancer,  but  it  differs  in 
some  of  its  appearances  from  what  is  acknowledged  to  be 
the  true  cancer  in  other  parts  of  the  body.* 

Enlargement  and  Hardness  of  the  Uterus. 

It  sometimes  happens,  although  not  very  often,  that  the 
uterus  enlarges  in  its  size,  and  becomes  much  harder 
than  in  its  natural  state.  This  change  corresponds  in 
some  respects  to  that  of  scirrhus  in  other  parts  of  the  body, 
and  commonly  extends  over  the  whole  of  the  uterus.  It 
is  difficult  to  say  to  what  size  the  uterus  may  at  length 
arrive,  in  the  progress  of  this  disease,  but  I  have  seen  it, 
in  one  case,  astlarge  as  the  gravid  uterus  at  the  sixth 

*  This  diseased  change  I  formerly  confounded  with  the  scirrhous  enlarge- 
ment of  the  uterus,  considering  them  as  varieties  of  the  same  disease,  and 
therefore  blending  their  description  together;  but  in  consequence  of  the 
accurate  observations  of  Dr.  Adams,  in  his  Essay  upon  Morbid  Poisons,  I  have 
thought  it  proper  to  separate  them. 


230 

month.  If  a  transverse  section  be  made  of  the  uterus  in 
this  state,  it  is  found  to  consist  of  a  hard  substance,  inter- 
sected by  thick  membranes.  Ulceration  hardly  ever  takes 
place  in  this  condition  of  the  uterus.  I  recollect  one 
instance,  in  which  there  was  some  appearance  of  it,  but 
I  may  have  made  this  remark  too  hastily,  and  may  have 
been  deceived.  Tubercles  are  -occasionally  formed  in 
this  state  of  the  uterus,  being,  as  it  were,  imbedded  in  its 
substance,  and  they  have  a  structure  very  much  resem- 
bling that  of  the  uterus  itself. 

Tubercles  of  the  Uterus. 

Hard  tubercles  often  grow  from  the  uterus,  which  are 
either  imbedded  in  its  substance,  or  arise  from  its  outer 
surface.  They  vary  a  good  deal  in  their  size,  viz.  from 
that  of  a  hazel  nut,  to  more  than  the  size  of  the  fist.  They 
are  irregular  in  their  shape,  but  are  commonly  rounded, 
and  are  often  in  some  degree  knotted.  These  when  cut 
into,  exhibit  a  hard  whitish  substance,  intersected  by 
membranous  septa,  which  are  commonly  very  thick  and 
strong.  They  have  little  or  no  disposition  to  ulcerate. 
The  uterus  in  this  state  of  disease,  is  generally  of  the 
natural  size,  and  possesses  the  healthy  structure,  but 
occasionally  it  is  much  enlarged. 

A  mass  of  the  same  kind  is  sometimes  found  in  the 
cavity  of  the  uterus,  and  often  grows  to  a  very  large  size. 
I  have  seen  it  a  good  deal  larger  thaif  a  child's  head  at 
birth.  This  mass  when  cut  into,  exhibits  precisely  the 
same  appearances  as  those  which  we  have  so  lately  de- 
scribed. It  is  remarkable,  that  such  masses  within  the 
cavity  of  the  uterus  commonly  do  not  adhere  in  any  part 
closely  to  it,  but  are  connected  with  it  loosely,  by  the 


intervention  of  cellular  membrane,  and  small  blood  vessels, 
so  that  they  can  be  very  easily  peeled  off,  without  in- 
juring the  structure  of  the  uterus.  The  uterus  itself  is 
more  or  less  enlarged  according  to  the  bulk  of  the  mass 
it  contains,  but  it  appears  to  be  perfectly  healthy  in  its 
structure. 

Polypus. 

Polypus  forms  a  very  common  disease  of  the  uterus.; 
and  may  take  place  almost  at  any  period  of  life;  it  is  more 
frequent,  however,  at  middle  or  advanced  age,  and  rarely 
happens  in  persons  who  are  young.  By  a  polypus  is 
meant  a  diseased  mass,  which  adheres  to  some  part  of  the 
cavity  of  the  uterus,  by  a  sort  of  neck  or  narrower 
portion.  It  is  of  different  kinds;  the  most  common  kind 
is  hard,  and  consists  of  a  substance,  divided  by  thick 
membranous  septa.  When  cut  into,  it  shews  precisely 
the  same  structure  of  the  tubercle  of  the  uterus  just  de- 
scribed; so  that  a  person  looking  upon  a  section  of  the  one 
and  the  other,  out  of  the  body,  could  not  at  all  distinguish 
between  them.  This  sort  of  polypus  varies  very  much 
in  its  size,  some  being  not  larger  than  a  walnut,  and  others 
being  larger  than  a  child's  head.  It  adheres  by  a 
narrower  portion  or  neck,  which  varies  a  great  deal  in  its 
size,  and  in  its  proportion  to  the  body  of  the  polypus. 
The  largest  polypus  I  ever  saw  was  suspended  by  a  neck 
hardly  thicker  than  the  thumb ;  and  I  have  seen  a  poly- 
pus, less  than  the  fist,  adhering  by  a  neck  fully  as  thick 
as  the  wrist. 

The  place  of  adhesion  also  differs  considerably.  It  is 
most  commonly  at  the  fundus  uteri,  but  it  may  take 
place  in  any  other  part;  and  I  have  seen  a  small  polypus 


232 

adhering  just  on  the  inner  part  of  the  lip  of  the  os  uteri. 
When  a  polypus  is  of  any  considerable  size,  there  is  gene- 
rally one  only;  but  I  have  occasionally  seen  on  the  inside  of 
the  uterus,  two  or  three  small  polypi,  and  in  some  instances, 
several  polypi  have  been  known  to  grow  from  the  uterus 
in  succession. 

Another  sort  of  polypus  takes  place  in  the  uterus, 
which  consists  of  an  irregular,  bloody  substance,  with  a 
number  of  tattered  processes  hanging  from  it.  This  when 
cut  into  exhibits  two  different  appearances  of  structure;  the 
one  appearance  is  that  ^of  a  spongy  mass,  consisting  of 
laminae,  with  small  interstitial  cavities  between  them;  the 
other  is  that  of  a  very  loose  texture,  consisting  of  large 
irregular  cavities.  It  is  very  obvious,  that  in  proportion 
as  a  polypus  grows,  the  cavity  of  the  uterus  must  be  en- 
larged, and  the  same  change  must  take  place  in  the  vagina, 
when  a  polypus  protrudes  from  the  uterus  into  this  canal. 

The  Inversion  of  the  Uterus. 

The  inversion  of  the  uterus  occasionally  takes  place, 
and  principally  from  two  causes,  viz.  from  the  weight 
of  a  polypus,  or  from  violent  pulling,  in  attempts  to 
remove  the  placenta.  When  the  inversion  is  incomplete, 
the  fundus  uteri  forms  a  tumour  within  its  cavity;  there 
is  at  the  same  time  an  appearance  of  fissure  upon  the 
outside  of  the  uterus,  where  the  fundus  usually  is ;  and 
the  Fallopian  tubes,  the  round  ligaments,  and  the  ligaments 
of  the  ovaria,  are  drawn  inwards  at  both  edges  of  the 
fissure.  The  uterus,  particularly  after  labour,  is  some- 
times inverted  entirely,  the  inner  surface  being  exposed, 
and  the  fundus  uteri  forming  a  large  tumour  within  the 
vagina,  and  in  some  cases  even  on  the  outside  of  the  lab ia. 


233 


Prolapsus  Uteri. 

The  uterus  sometimes  leaves  its  natural  situation  and 
fails  downwards,  so  as  either  to  get  to  the  external  parts, 
or  out  of  the  body  entirely.  This  is  most  apt  to  happen 
when  women  have  a  large  pelvis,  and  where  the  soft  parts 
have  been  very  much  relaxed  by  repeated  and  severe 
labours.  This  disease  is  called  prolapsus  uteri,  and  will 
be  explained  more  particularly  when  we  come  to  treat  .of 
the  diseases  of  the  vagina.  It  is  much  more  frequent 
than  the  other  disease  called  the  inversio  uteri. 

Stricture  in  the  Cavity  of  the  Uterus. 

A  stricture  is  sometimes  formed  within  the  cavity  of 
the  uterus,  so  that  its  cavity  at  one  part  is  obliterated 
entirely.  This  I  believe  almost  always  to  take  place  at 
one  part,  viz.  where  the  cavity  of  the  fundus  uteri  termi- 
nates, and  that  of  the  cervix  begins,  for  in  this  place  the 
cavity  of  the  uterus  is  narrowest.  As  the  sides  of  the 
cavity  round  this  place  lie  very  near  each  other,  and  form 
naturally  a  small  aperture,  it  is  probable  that  some  slight 
inflammation  may  unite  the  parts  together,  and  shut  up 
the  aperture ;  or  the  parts  may  gradually  approach  each 
other  without  this  cause,  as  in  strictures  of  the  urethra. 

The  Os  Uteri  contracted,  and  closed  up. 

The  os  uteri  has  been  found  to  be  so  contracted,  as  to 
have  its  passage  in  a  great  measure  obliterated;*  and  it 
has  even  been  known  to  be  closed  up,  by  the  growth  of 
an  adventitious  membrane. f 

*  Vid.  Morgagni,  Epist.  LXVII.  Art.  11. 
f  Vid.  Morgagni,  Epist  XLVJ.  Art.  17. 

2G 


234 


Uterus  bony* 

The  substance  of  the  uterus  is  sometimes  more  or  less 
converted  into  bone.  This  arises  from  a  particular  morbid 
action  of  its  blood  vessels,  by  which  they  secrete  from 
the  blood  bony  matter,  and  it  is  a  very  rare  disease. 

The  Uterus  changed  into  an  earthy  Substance. 

The  uterus  has  also  been  known  to  be  converted  into 
an  earthy  substance.*  It  is  probably  of  the  same  kind 
with  the  earth  of  bones ;  and  this  disease  probably  differs 
only  from  the  former,  in  there  being  a  less  proportion  of 
animal  gluten,  to  combine  the  earthy  particles  together. 

A  bony  Mass  in  the -Cavity  of  the  Uterus. 

In  the  cavity  of  the  uterus. a  bony  mass  is  sometimes 
found.  When  this  is  the  case,  I  suspect  that  the  hard 
fleshy  tubercle  within  the  cavity  of  the  uterus,  such  as 
we  lately  described,  has  been  converted  into  bone.  This 
at  least  had  taken  place  in  the  only  instance  which  I  have 
known  of  this  disease  (for  a  great  part  of  the  tubercle  still 
remained  unchanged)  and  I  think  it  very  probable,  that 
such  a  change  most  frequently  happens,  where  these  bony 
tumours  are  found. 

Stones  in  the  Cavity  of  the  Uterus. 

Stonesf  have  sometimes  been  found  in  the  cavity  of 
the  uterus.  These  are  described  by  authors  as  varying 
in  their  appearance,  some  being  of  a  dark,  and  others  of 
a  light  colour.  About  their  nature  they  are  silent,  and  I 

*  Vid.  Lieutaud,  Tom.  I.  p.  323. 
f  Vid.  Lieutaud,  Tom.  I.  p.  339. 


235 

can  say  nothing  of  it  from  my  own  knowledge,  as  it  has 
never  occured  to  me  to  see  an  instance  of  this  disease. 
Such  concretions  are  probably  formed  from  matter  thrown 
out  by  the  small  arteries  which  open  upon  the  internal 
surface  of  the  uterus,  and  are  in  some  degree  analogous 
to  the  concretions  which  are  formed  in  some  glands  of 
the  body. 

Dead  Foetus  in  the  Uterus  converted  into  an  earthy  Mass. 

It  has  also  been  known  to  happen,  that  a  dead  foetus  has 
remained  for  a  long  time  in  the  cavity  of  the  uterus,  and 
has  there  been  gradually  changed  into  an  earthy  mass  pre- 
serving the  shape  of  the  child.* 

Water  in  the  Cavity  of  the  Uterus. 

Water  has  sometimes  been  known  to  be  accumulated 
in  the  cavity  of  the  uterus  in  very  large  quantity.!  In 
some  cases  fifty,  sixty,  or  even  a  hundred  pints,  have 
been  said  to  be  accumulated.  This  water  is  sometimes 
bloody  in  its  appearance,  and  sometimes  of  a  yellowish 
colour.  Of  its  nature  I  cannot  speak  particularly,  as  I 
ha.ve  never  seen  an  instance  of  this  disease.  I  think  it 
probable,  however,  that  the  water  accumulated  in  the 
cavity  of  the  uterus,  resembles  in  its  properties  the  serum; 
and  that  it  is  poured  out  by  the  small  curling  arteries  of 
the  uterus.  In  cases  where  water  is  really  accumulated 
in  the  cavity  of  the  uterus,  one  must  suppose  a  stricture 
of  the  cervix,  otherwise  the  water  would  escape  gradually 
into  the  vagina  as  it  is  formed.  I  am  disposed  to  believe, 
however,  that  where  water  has  been  said  to  be  accumula- 

*  See  Cheselden's  Anatomy  of  the  Bones,  plate  LVI. 

-  Vid.  Lieutaud,  Tom.  I.  p.  319,  p.  333. 


236 

ted  in  the  cavity  of  the  uterus,  it  has  frequently  been 
really  in  one  or  more  large  hydatids  formed  in  that  cavity.* 

Hydatids  in  the  Uterus. 

Large  masses  of  hydatidsf  have  also  been  found  in  the 
cavity  of  the  uterus.  Whether  these  be  commonly  of  the 
same  kind  with  what  occasionally  grow  in  the  placenta, 
or  like  those  in  other  parts  of  the  body,  I  cannot  determine, 
as  it  has  not  occurred  to  me  to  see  an  example  of  this 
disease.  The  hydatids  of  the  placenta  are  a  good  deal 
different  from  those  of  the  liver,  kidneys,  and  some  other 
parts  of  the  body.  They  consist  of  vesicles  of  a  round  or 
oval  shape,  with  a  narrow  stalk  to  each,  by  which  they 
adhere  on  the  outside  of  one  another.  Some  of  these 
hydatids  are  as  large  as  a  walnut,  and  others  as  small  as  a 
pin's  head.  A  large  hydatid  has  generally  a  number  of 
small  hydatids  adhering  to  it  by  narrow  processes.  Of 
their  real  nature  nothing  is  known,  but  they  are  probably 
animals  of  a  very  simple  structure.  In  the  same  quad- 
ruped different  species  of  hydatids  will  sometimes  occur, 
and  therefore  the  same  thing  may  take  place  in  the  human 
subject.  I  believe  that  the  hydatids  said  to  be  found  in 
the  uterus,  have  not  uncommonly  been  only  hydatids  of 
the  placenta,  which  had  been  retained  there. 

Air  in  the  Uterus. 

Air  has  sometimes  been  known  to  be  accumulated  in 
the  cavity  of  the  uterus,  but  this  occurs  very  rarely,  and 
has  not,  except  in  one  instance,  fallen  under  my  own 

*  Dr.  Denman  has  had  an  opportunity  of  observing  a  case,  where  water 
was  accumulated  in  one  large  hydatid  of  the  uterus. 
|  Vid.  Lieutaud,  Tom.  I.  p.  335. 


237 

observation.  The  air  when  so  accumulated  sometimes 
escapes  through  the  os  uteri  with  a  noise  somewhat  sim- 
ilar to  that  which  is  occasioned  by  the  escape  of  air  from 
the  rectum.  This  air  is  probably  formed  by  the  small 
blood  vessesls  of  the  uterus  in  a  manner  analogous,  to 
secretion,  and  its  properties  are  at  present  unknown.* 

Rupture  of  the  Uterus. 

These  are  the  various  diseased  apperances  which  are 
well  ascertained  to  take  place  in  the  uterus.  I  have  to 
add,  that  the  womb  is  not  unfrequently  ruptured,  which 
is  rather  to  be  considered  as  an  accident  than  a  disease. 
This,  perhaps,  never  takes  place  but  in  the  pregnant  uterus, 
and  at  the  time  of  labour;  and  it  chiefly  arises  from  the 
too  violent  action  of  the  muscular  fibres  of  the  uterus 
upon  the  child,  when  there  is  more  than  the  ordinary  re- 
sistance to  its  expulsion.  The  ruptures  which  I  have  seen 
have  been  commonly  in  the  side  of  the  womb,  and  of 
considerable  extent.  The  peritonaeum  covering  the  womb 
sometimes  remains  whole,  and  there  is  a  large  mass  of 
black  coagulated  blood  lying  between  it  and  the  uterus, 
where  the  rupture  has  taken  place.  This  black  appearance 
is  occasionally  mistaken  for  mortification. 

Two  Uteri. 

It  has  sometimes  happened,  although  very  rarely,  that 
two  uteri  have  been  formed  in  the  same  person  instead  of 
one.  In  this  case  there  is  but  one  ovarium  and  one 
Fallopian  tube  to  each.  The  vagina  is  at  the  same  time 
divided  by  a  septum  into  two  canals,  each  of  which  con- 
ducts to  its  proper  uterus.  In  the  case  which  is  described 

*  Vid.  Portal's  Anatomic  Medicale,  Tom.  V.  p.  525. 


238 

iu  the  Philosophical  Transactions,*  a  communication 
was  formed  at  one  part  through  the  septum;  but  how  far 
this  generally  takes  place  in  such  a  kind  of  monstrosity, 
I  cannot  determine. 

Natural  Varieties  in  the  Uterus. 

The  uterus  varies  a  good  deal  in  its  size  in  different 
persons,  in  some  being  fully  twice  as  large  as  it  is  in 
others.  It  differs  also  somewhat  in  the  thickness  of  its 
substance.  There  is  some  difference  too  in  its  situation, 
being  often  placed  nearer  one  side  of  the  pelvis  than  the 
other.  All  of  these  are  to  be  considered  as  varieties  in 
the  natural  formation,  and  not  as  disease. f 


SYMPTOMS. 

In  inflammation  of  the  uterus,  there  is  a  sense  of  pain 
and  tension  in  the  hypogastric  region,  and  the  pain  is 
increased  upon  pressure  there,  or  upon  touching  the  os 
uteri.  The  stomach  is  affected  with  vomiting,  and  the 
bowels  are  sometimes  costive,  and  sometimes  disposed  to 
looseness.  The  whole  constitution  is  roused  into  action, 
exhibiting  those  symptoms  which  have  been  called  fever, 
and  the  pulse  has  commonly  a  great  degree  of  frequency. 
When  the  peritonaeum  is  inflamed  over  the  general  sur- 

*  See  Philosophical  Transactions,  Vol.  LXIV.  p.  474. 

j  A  very  excellent  and  ample  account  of  these  diseases  of  the  uterus  lias 
been  lately  published  by  Mr.  Clarke,  which  may  be  consulted  by  medical 
practitioners  with  great  advantage. 


239 

face  of  the  abdomen,  or  to  a  considerable  extent,  there  is 
a  general  swelling  of  that  cavity,  with  pain  and  extreme 
tenderness  upon  pressure,  and  the  feverish  symptoms 
are  increased. 


In  the  malignant  ulcer  of  the  uterus  there  is  a  sense 
of  pain  in  the  hypogastric  region,  which  is  often  very 
violent.  At  the  same  time  there  is  commonly  felt  a  dull 
pain  round  the  hips  and  down  the  thighs.  Mucus,  pus, 
and  blood  are  frequently  discharged  by  the  vagina,  and 
the  quantity  of  blood  is  sometimes  very  large.  The  pulse 
at  the  beginning  of  this  dreadful  disease  is  natural,  and 
the  general  health  is  but  little  impaired,  but  when  it  is 
far  advanced,  the  pulse  becomes  quick,  the  countenance 
sallow,  and  the  body  emaciated. 

If  in  the  progress  of  the  disease  a  communication  should 
be  formed  between  the  vagina  and  the  urinary  bladder, 
the  urine  will  then  pass  off  by  the  vagina.  Some  of  the 
glands  of  the  groin,  in  advanced  stages  of  the  disease, 
often  become  hard  and  enlarged  in  their  size. 


In  the  scirrhous  enlargement  of  the  uterus,  there  are 
a  few  symptoms  to  characterize  it  till  the  disease  has 
made  considerable  progress.  There  is  pain  in  the  hy- 
pogastric region  and  round  the  hips,  which  is  more  or 
less  acute  in  different  cases;  but  this  is  common  to  it 
with  several  other  diseases.  When  the  disease,  however, 
is  a  good  deal  advanced,  it  may  be  ascertained  by  an  ex 


240 

animation  by  the  vagina.  The  os  tincae  will  then  feel 
enlarged  and  hard,  and  there  will  be  an  unusual  sense  of 
weight  against  the  finger  from  the  increased  size  of  the 
uterus.  A  tumour  may  at  the  same  time  be  distinctly  felt 
above  the  pubes.  This  disease  is  commonly  attended  with 
mucous  discharges  from  the  vagina,  and  profuse  dis- 
charges of  blood  at  the  monthly  periods.  The  pulse  is 
generally  natural,  and  the  health  not  much  impaired. 


When  tubercles  formed  upon  the  outer  surface  of  the 
uterus  or  imbedded  in  its  substance  are  small,  and  the 
uterus  is  nearly  of  its  natural  size,  little  inconvenience  is 
probably  produced  by  them.  When  the  tubercles  how- 
ever are  large,  they  will,  according  to  their  size  and 
situation,  produce  more  or  less  difficulty  in  passing  the 
urine,  or  in  passing  the  freces.  When  a  tubercle  grows 
from  the  anterior  surface  of  the  fundus  uteri,  and  is  large, 
and  the  patient  rather  of  a  spare  habit,  its  existence  and 
nature  may  be  satisfactorily  ascertained  by  an  examination 
in  the  living  body. 


The  symptoms  which  attend  a  polypus  of  the  uterus, 
are  mucous  and  occasional  bloody  discharges  by  the 
vagina,  with  frequent  pains  round  the  hips.  When  it  has 
made  considerable  progress  in  its  growth,  it  may  be 
ascertained  by  an  examination  by  the  vagina.  Even 
without  this  examination,  it  may  be  distinguished  from 
an  ulcer  of  the  uterus,  by  attention  to  the  history  of  its 


241 

progress,  and  by  the  general  health  being  much  less 
affected  in  this  case  than  when  an  ulcer  has  been  formed. 
The  glands  of  the  groin  are,  I  believe,  never  affected  from 
a  polypus,  but  are  often  tainted  by  absorption  in  advance^ 
stages  of  the  ulcerated  uterus. 


When  there  is  a  part  of  the  fundus  uteri  inverted, 
forming  a  tumour  in  the  cavity  of  the  uterus,  there  are  no 
symptoms  by  which  it  can  be  sufficiently  distinguished  in 
the  living  body.  It  is  attended  with  a  profuse  haemorr- 
hage, and  if  the  patient  should  survive,  the  menstrual 
flux  is  in  very  large  quantity,  together  with  very  copious 
mucous  discharges  in  the  intermediate  times.  When 
the  inversion  is  complete,  it  can  be  ascertained  by  an 
examination  of  the  tumour,  but  is  not  distinguished  by 
any  peculiar  symptoms.  The  attempts  which  have  been 
made  to  return  the  uterus  to  its  natural  situation,  have 
almost  alwavs  been  unsuccesful. 


Prolapsus  uteri  is  attended  with  more  or  less  of  pain 
in  the  loins  and  also  with  a  pain  in  the  groins  which  shoots 
down  to  the  labia.  There  is  more  or  less  of  a  mucous 
discharge  from  the  vagina,  and  sometimes  there  is  stran- 
guary.  There  is  also  a  sensation  of  bearing  down,  and 
of  weight  in  the  region  of  the  parts  affected.  These 
symptoms  disappear  or  are  very  much  lessened,  when  the 
patient  has  been  for  a  short  time  in  a  horizontal  posture. 
The  exact  circumstances  belonging  to  this  complaint 
2H 


242 


cannot  however  be  fully  ascertained  without  an  examina- 
tion, and  therefore  the  patient  should  be  always  advised 
to  allow  of  an  examination  being  made. 


There  are  no  symptoms  by  which  dropsy  of  the  uterus 
can  be  distinguised  from  some  other  conditions  of  this  or- 
gan, and  therefore  it  is  only  known  in  consequence  of  the 
evacuation  of  the  water,  by  the  vagina. 

There  will  of  course  be  more  or  less  enlargement  of 
the  uterus,  and  fullness  of  the  hypogastric  region,  in  pro- 
portion to  the  accumulation  of  the  water,  and  this  will 
subside  when  the  water  is  evacuated. 


The  existence  of  hydatids  in  the  uterus  is  not  distin- 
guished by  any  characteristic  symptoms,  and  is  only 
known  in  consequence  of  their  expulsion,  by  the  contrac- 
tile power  of  this  viscus.  This  generally  takes  place? 
and  is  attended  with  pains  resembling  very  much  the 
pains  of  labour. 


A  rupture  of  the  uterus  can  only  be  fully  ascertained 
by  an  examination.  It  is  attended  with  pain,  with  a  sense 
of  something  having  given  way  in  the  belly,  and  with 
almost  an  immediate  vomiting  of  a  chocolate -coloured 
matter.  The  uterus  gives  up  its  natural  efforts  for  the 
expulsion  of  the  child,  so  that  the  labour  pains  cease; 
the  child  is  retracted,  and  generally  escapes,  either  wholly 
or  in  part,  into  the  cavity  of  the  abdomen. 


243 


CHAPTER  XX. 


DISEASED    APPEARANCES  OF   THE   OVARIA. 

Inflammation  of  the  Peritoneal  Covering  of  the  Ovaria. 

THE  portion  of  the  peritonaeum  which  covers  the 
ovaria  I  believe  is  seldom  inflamed,  unless  where  the  in- 
flammation has  spread  to  it  from  the  uterus,  or  where  it 
has  attacked  this  membrane  generally.  It  is  not  unusual, 
however,  for  it  to  be  inflamed  under  both  of  these  circum- 
stances ;  and  it  shows  the  same  appearances  as  the  inflam- 
mation of  the  peritonaeum  covering  any  other  part.  Ad- 
hesions too  are  frequently  found,  joining  the  ovaria  to  the 
neighbouring  parts,  which  had  been  the  consequence  of 
such  an  inflammation. 

Inflammation  of  the  Substance  of  the  Ovaria. 

Where  the  uterus  has  been  inflamed  to  a  considerable 
degree,  as  after  parturition,  the  substance  of  the  ovaria 
has  also  been  occasionally  attacked  by  the  inflammation 
spreading  to  it.  The  ovaria  are  then  enlarged,  are  harder 
than  in  a  natural  state,  and  are  highly  vascular;  very  com- 
monly pus  is  found  to  have  been  formed. 

Enlargement  and  Hardness  of  the  Ovaria. 

The  ovaria  sometimes  become  considerably  enlarged, 
and  are  converted  into  a  whitish  hard  mass,  which  is  more 
or  less  intersected  with  membranous  septa.  This  change 
of  structure  is  similar  to  what  takes  place  in  the  fleshy 


244 

tubercle  oi  the  uterus  lately  described,  and  I  believe  has 
no  tendency  to  ulcerate,  but  it  occurs  much  more  rarely, 
than  this  disease  of  the  uterus.  These  hard  masses  have 
sometimes  a  disposition  to  be  converted  into  bone;  and  in 
this  way  most  frequently,  I  believe,  the  ovaria  become 
bony.  The  bony  substance  into  which  they  are  con- 
verted has  sometimes  a  greater  admixture  of  earth  than 
the  natural  bones  of  the  body. 

Ovaria  enlarged  and  changed  into  a  pulpy  Substance. 

The  ovaria  are  sometimes  very  much  enlarged,  and 
converted  into  a  pulpy  matter  of  a  smooth  uniform  texture. 
Cells  are  often  formed  in  a  part  of  this  substance,  which 
contain  a  fluid. 

Ovaria  scrofulous. 

The  ovaria  are  sometimes  changed  into  a  true  scrofulous 
matter,  intermixed  with  cells. 

Dropsy  of  the  Ovaria. 

The  most  common  disease  of  the  ovaria  is  dropsy. 
The  whole  substance  of  an  ovarium  is  sometimes  con- 
verted into  a  capsule  containing  a  fluid.  The  capsule  is 
frequentl}r  of  a  large  size:  it  consists  of  a  white  firm 
membrane,  and  contains  an  aqueous  fluid,  capable  of  being 
partly  coagulated. 

When  the  ovaria  have  become  dropsical,  and  their 
natural  structure  has  entirely  disappeared,  it  is  very  com- 
mon for  them  to  be  converted  into  a  number  of  cells, 
which  communicate  with  each  other  by  considerable 
openings,  and  to  be  prodigiously  enlarged.  An  ovarium 
in  this  case  may  be  so  increased  in  size  as  to  occupy 


245 
*i 
almost  the  whole  cavity  of  the  abdomen.     The  ovaria  are 

also  sometimes  converted  into  a  congeries  of  cysts,  which 
have  no  communication  with  each  other.  These  vary 
a  good  deal  in  their  size,  some  being  not  larger  than  a 
hazel  nut,  and  others  as  large  as  an  orange.  Their  coats 
are  sometimes  thin,  sometimes  of  considerable  thickness, 
and  consist  of  a  compact,  white,  laminated  membrane. 
They  contain  either  a  serous  fluid,  with  which  I  have  seen 
some  slimy  matter  mixed,  or  a  thick  ropy  fluid,  or  a  kind 
of  jelly.  This  jelly  is  sometimes  so  tough  that  it  can  be 
drawn  out  to  a  considerable  length,  and  when  it  breaks,  it 
passes  back  with  a  great  deal  of  elastic  force.  Different 
cysts  in  the  same  ovarium  will  sometimes  contain  different 
sorts  of  fluid,  a  circumstance  which  one  would  not  expect 
a  priori. 

It  sometimes  also  happens,  although  rarely,  that  some 
pus  is  found  in  one  or  more  cysts  of  a  dropsical  ovarium, 
mixed  with  the  serum  or  the  jelly  which  is  accumulated 
there.  This  has  been  produced  by  inflammation  in  some 
part  of  the  inner  surface  of  the  ovarium,  occasioned 
probably  by  the  great  distention  of  that  part,  in  conse- 
quence of  the  accumulation  of  fluid  there.  A  large 
quantity  of  pus  has  sometimes  been  found,  where  in- 
flammation has  been  extended  over  a  large  portion  of  the 
inner  surface  of  the  ovarium,  and  this  has  most  frequently 
taken  place,  where  inflammation  has  been  produced  in 
consequence  of  the  operation  of  tapping  the  ovarium. 

These  cysts,  I  believe,  have  been  occasionally  con- 
founded with  hydatids,  to  which  they  bear  some  re- 
semblance. They  are  however  really  very  different.  They 
have  much  firmer  and  less  pulpy  coats  than  hydatids;  they 
contain  a  different  kind  of  fluid,  and  they  are  different! v 


246 

connected  among  themselves.  Hydatids  either  lie  un- 
connected with  each  other,  or  a  large  hydatid  incloses  a 
number  of  small  ones;  or  smaller  hydatids  adhere  to  the 
coats  of  those  which  are  larger.  Cysts  of  the  ovarium 
adhere  to  each  other  laterally  by  pretty  broad  surfaces; 
do  not  inclose  each  other;  and  appear  to  have  no  power 
analogous  to  generation  as  hydatids  have,  by  which  smaller 
cysts  are  formed,  that  are  attached  to  those  of  a  larger  size. 
It  appears  not  improbable,  that  these  cysts  are  formed  by 
a  gradual  enlargement  of  the  small  vesicles  which  make 
a  part  of  the  natural  structure  of  the  ovaria. 

The     Ovaria   changed   into    a   Fatty    Substance    with 
Hair  and  Teeth. 

The  ovaria  is  sometimes  converted  into  a  fatty  sub- 
stance, intermixed  with  long  hair  and  teeth,  which  is 
surrounded  by  a  capsule  consisting  of  a  white  strong 
membrane.  The  hairs  are  most  of  them  loose  in  the  fatty 
substance,  but  many  of  them  also  adhere  on  the  inside 
of  the  capsule.  Teeth  too  are  formed,  but  are  generally 
incomplete,  the  fangs  being  wanting.  These  sometimes 
arise  immediately  from  the  inner  membrane  of  the  capsule, 
and  are  sometimes  connected  with  an  irregular  mass  of 
bone.  Such  productions  have  been  commonly  considered 
as  very  imperfect  ova,  in  consequence  of  impregnation; 
but  there  is  good  reason  to  believe  that  they  can  take 
place  without  any  intercourse  between  the  sexes,  I  have 
described  a  case,  which  has  been  published  in  the  Philo- 
sophical Transactions,  where  it  was  hardly  possible  that 
impregnation  could  have  happened.  The  girl  in  whom 
this  change  of  the  ovarium  was  found,  could  not  from  all 
appearances  have  been  more  than  twelve  or  thirteen  years 


247 

old;  the  hymen  was  perfect;  and  the  uterus  had  not  re- 
ceived that  increase  of  bulk  which  is  usual  at  puberty. 
The  other  marks  of  puberty  were  also  wanting.  From 
these  circumstances  I  should  judge  the  womb  to  have 
been  incapable  of  the  stimulus  of  impregnation.  A  tu- 
mour, consisting  of  teeth  and  hair,  was  preserved  by  the 
celebrated  Ruysch*  in  his  collection,  which  he  says  was 
found  in  a  man's  stomach.  If  this  -be  true  (which  there 
seems  to  be  no  reason  to  doubt),  it  puts  my  conjecture 
beyond  dispute.  This  production  could  not  possibly, 
under  such  circumstances,  have  any  connection  with  im- 
pregnation ;  and  if  it  occurs  without  it  in  one  part  of  the 
body,  there  can  be  no  good  reason  why  it  may  not  also 
take  place  without  impregnation  in  another  part.  These 
productions  are  much  more  frequent  in  the  ovaria  than 
any  where  else,  probably  because  the  process  which  forms 
them  bears  some  analogy  to  generation,  in  which  the 
ovaria  are  materially  concerned.  I  must  still  therefore, 
whatever  objections  have  been  made  to  it,  retain  my  for. 
mer  opinion.  These  masses  in  the  ovaria  are  commonly 
about  the  size  of  a  large  orange,  f 

*  Vid.  Ruysch,  Tom.  II.  Adverser.  Anatomicor.  Decad.  tert. 

f  I  have  very  lately  met  with  the  same  kind  of  fatty  substance  intermixed 
with  hair,  and  the  body  of  one  tooth  covered  with  enamel,  in  the  ovarium  of  a 
young  woman  about  eighteen  years  of  age.  In  this  case  the  uterus  was  rather 
less  than  its  usual  size  in  the  adult  when  unimpregnated,  and  there  was  no 
membrana  decidua  whatever  formed  in  its  cavity.  It  appeared  therefore,  to 
be  undergoing  no  change  similar  to  what  happens  when  there  is  an  ovum  grow- 
ing in  the  ovarium  or  the  Fallopian  tube.  The  hymen  too  was  perfect,  the 
edge  of  the  membrane  being  quite  sound  and  natural,  and  the  aperture  in  it 
being  remarkable  small.  These  circumstances  do  not  amount  to  demonstrative 
evidence,  but  still  must  be  considered  as  a  very  strong  confirmation  of  the 
truth  of  the  opinion  above  stated. 

I  have  been  informed  by  Mr.  Colman,  that  a  dead  gelding  was  some  time 
ago  examined,  in»  which  a  cyst  was  found  a  little  under  the  right  kidney,  con- 


A  Foetus  in  the  Ovarium. 

A  foetus  is  sometimes  found  in  the  ovarium.  This 
seldom  arrives  at  the  full  size,  but  its  formation  as  far  as 
it  goes  is  commonly  perfect.  When  this  happens,  all 

taining  a  fatty  matter,  hair,  and  some  teeth.     This  fully  establishes  the  truth 
of  the  opinion  above  stated. 

The  particulars  discovered  by  dissection  are  very  curious,  and  are  so  clearly 
atated  by  Mr.  Colnvan,  that  I  shall  take  the  liberty  of  subjoining  the  account  of 
then\  in  his  own  words  : 

"  A  bay  gelding,  seven  years  old,  belonging  to  the  Royal  Horse  Artillery  at 
Woolwich,  was  attacked  with  a  contagious  and  incurable  disease,  (viz.  glanders) 
in  consequence  of  which  I  recommended  that  the  horse  should  be  destroyed. 
After  the  morbid  parts  concerned  in  this  disease  had  been  examined,  Mr. 
Percivall,  Veterinary  Surgeon  to  the  Most  Honourable  Board  of  Ordnance, 
(whose  attention  to  anatomy  and  his  profession  in  general  deserves  the  highest 
enconiums)  accidentally  opened  the  cavity  of  the  abdomen,  and  discovered  a 
tumour  about  the  size  of  a  horse's  testicle,  of  an  oblong  form,  a  little  below  the 
right  kidney,  and  loosely  attached,  by  a  long  slender  neck,  to  the  peritoneum. 
Mr.  Percivall  removed  this  tumour  without  supposing  that  the  contents  were 
peculiar,  but  as  the  inner  parts  felt  as  if  they  were  of  a  bony  nature,  a  longitu- 
dinal section  was  made  with  a  saw  completely  through  its  substance.  It  now  ap- 
peared that  the  other  cyst  of  the  tumour  contained  two  small  molar  horse-teeth, 
and  one  incisor  tooth,  with  a  portion  of  bone  attached  to  this  tooth  resembling 
the  jaw.  The  remainder  of  the  tumour  was  composed  of  about  two-thirds  of 
fat  and  one-third  of  hair  ot  a  black  colour  contained  in  a  separate  cyst.  The 
molar  teeth  which  were  fortunately  divided  by  the  saw  longitudinally  near  the 
rentre,  had  the  same  arrangement  of  enamel  and  bony  matter  as  natural  horses' 
teeth.  Two  very  small  blood  vessels  were  observed  going  from  the  neck  of 
the  tumour  into  its  substance,  but  they  were  not  attended  to  till  the  section  had 
been  made.  As  the  history  of  the  animal  from  its  birth  could  not  be  procured, 
it  cannot  be  ascertained  whether  both  testicles  had  previously  been  removed. 
It  is  posible  that  one  testicle  might  have  remained  in  the  abdomen,  and  the 
form,  situation,  and  size  of  the  tumour,  rather  favour  this  supposition.  But 
wether  blood  vessels  were  formed  from  the  neighbouring  parts  to  produce 
this  peculiar  organization,  or  whether  the  teeth  and  hair  were  produced  by 
the  spermatic  vessels,  the  process  is  equally  curious  and  inexplicable.  This 
phcenomenon,  however,  fully  establishes  the  opinion  of  Dr.  Baillie,  that  when 
teeth  and  hair  and  fat  are  found  in  the  ovarium,  impregnation  is  not  necessary 
to  their  formation,  and  therefore  it  is  highly  probable,  that  in  no  instance  it  has 
been  the  cause  of  these  extraordinary  productions  in  the  ovaria." 


249 

vestige  of  the  ovarium  is  lost,  and  instead  of  it  there  is  a 
bag  of  some  firmness  containing  the  foetus;  to  this  bag 
upon  the  inside  is  attached  a  placenta,  and  a  part  of  the 
chorion.  The  bag  can  be  ascertained  to  be  the  ovarium, 
by  tracing  upon  it  the  Fallopian  tube  and  the  spermatic 
vessels,  from  their  origin  to  their  termination.  The  uterus 
in  such  cases  is  considerably  larger  than  when  unimpreg- 
nated,  and  in  its  cavity  there  is  formed  the  membrana 
decidua.  This  shews  that  the  uterus  takes  on  the  same 
changes,  although  imperfectly,  which  it  does  in  the  ordi- 
nary circumstances  of  pregnancy.  The  spermatic  vessels 
are  also  enlarged,  in  order  to  supply  a  sufficient  quantity 
of  blood  to  the  ovum  which  is  growing  in  the  ovarium. 

Shrinking  of  the  Ovaria. 

The  ovaria  commonly  shrink  towards  old  age,  and  are 
changed  in  their  structure.  They  are  diminished  to  half 
their  natural  size,  are  somewhat  tuberculated  on  their 
surface,  and  are  hard.  When  cut  into,  the  vesicles,  which 
make  a  part  of  their  natural  structure,  are  found  to  be 
filled  with  a  white  solid  matter. 

One  Ovarium  or  both  -wanting. 

An  ovarium  on  one  side  has  been  known  to  be  wanting; 
but  this  is  extremely  rare.  An  example  of  this  kind  is 
preserved  in  Dr.  Hunter's  collection.  Some  instances 
have  been  recorded,  in  which  no  vestige  of  an  ovarium 
could  be  observed  on  either  side. 


9,1 


250 


SYMPTOMS. 


As  the  ovaria  are  very  seldom  inflamed,  unless  when 
inflammation  has  at  the  same  time  attacked  the  uterus ;  it 
is  not  known  whether  there  be  any  particular  symptoms 
which  characterize  inflammation  of  the  ovaria.  Inflam- 
mation of  the  ovaria  cannot  at  present  be  distinguished  by 
its  symptoms,  from  inflammation  of  the  uterus. 


A  hard  state  of  the  ovaria,  is  with  difficulty  determined 
in  the  living  body.  When  an  ovarium  of  this  kind  has 
increased  to  a  large  size,  and  lies  upon  the  side  of  the 
pelvis,  and  the  person  is  at  the  same  time  of  a  spare  habit, 
it  may  in  some  measure  be  ascertained  by  an  accurate 
examination  of  the  tumour  through  the  parietes  of  the 
abdomen.  The  tumour  will  feel  much  harder  than  where 
an  ovarium  is  enlarged  by  dropsy,  or  filled  with  cysts. 
When  the  ovarium  is  not  capable  of  being  accurately 
examined,  the  opinion  about  the  existence  of  this  disease 
must  rest  much  more  upon  probable  evidence,  than  upon 
any  clear  proof. 


Dropsy  of  the  ovarium  cannot  be  ascertained  in  a  very 
early  stage  of  this  disease.  But  when  it  has  made  con- 
siderable progress,  so  as  to  have  formed  a  swelling  at  the 
lower  part  of  the  belly,  it  may  commonly  be  ascertained 


251 

by  an  accurate  examination,  and  attention  to  the  history 
of  its  growth.  The  tumour  is  generally  on  one  side  of 
the  abdomen  more  than  the  other,  according  as  the  right 
or  left  ovarium  is  affected.  There  is  often  an  inequality 
in  the  surface  of  the  swelling,  and  an  obscure  kind  of 
fluctuation  is  felt  upon  striking  with  the  hand  the  parietes 
of  the  abdomen,  which  cover  the  swelling.  The  health 
is  commonly  very  little  affected  by  this  disease,  and  it  is 
slow  in  its  progress,  so  that  life  will  often  be  continued 
with  tolerable  comfort  under  it  for  many  years.  The 
quantity  of  the  urine  is  sometimes  little  diminished  below 
what  is  usual  in  health,  and  the  absorbents  of  the  ovarium 
are  hardly  capable  of  being  excited  to  a  vigorous  action 
by  medicine.  There  have  been  few  instances,  therefore, 
of  a  dropsy  of  the  ovarium  being  cured = 


252 


CHAPTER  XXL 


DISEASED    APPEARANCES    OF  THE  FALLOPIAN  TUBES. 

Inflammation  of  the  Fallopian  Tubes. 

WHEN  the  uterus  is  inflamed  to  a  considerable  degree, 
the  inflammation  often  spreads  along  the  Fallopian  tubes : 
they  become,  in  this  case,  highly  vascular,  and  when  cut 
open,  sometimes  contain  blood  in  their  cavities.  The 
inflammation  may  even  advance  to  suppuration,  when 
their  cavities  become  loaded  with  pus. 

Adhesions. 

When  the  peritonaeum  generally,  or  some  part  of  it,  in 
the  neighbourhood  of  the  Fallopian  tubes,  is  inflamed,  the 
external  covering  of  these  tubes,  which  is  a  continuation 
or  the  peritonaeum,  also  partakes  of  the  inflammation. 
This,  when  it  subsides,  generally  terminates  in  adhesions 
of  the  Fallopian  tubes  to  the  contiguous  parts.  It  is  not 
unusual  to  find  the  fimbriated  extremity  of  the  Fallopian 
tubes  adhering  to  the  ovaria ;  or  when  the  previous  in- 
flammation has  been  considerable,  to  find  the  fimbriated 
appearance  entirely  lost,  and  the  body  of  the  Fallopian  tube 
apparently  terminating  on  the  surface  of  the  ovarium. 
Under  such  circumstances  there  is  no  aperture  towards 
this  end  of  the  Fallopian  tubes,  and  it  has  lost  its  power 
of  conveying  the  ovum  from  the  ovarium  to  the  uterus. 

The  very  small  aperture  by  which  the  Fallopian  tube 


253 

communicates  with  the  cavity  of  the  uterus,  is  sometimes 
obliterated,  but  not  so  often  as  the  aperture  of  that  extrem- 
ity next  to  the  ovarium. 

Dropsy  of  the  Fallopian  Tubes. 

When  the  fallopian  tube  has  its  apertures  closed  at  both 
extremities,  it  is  sometimes  dilated  into  a  considerable 
tortuous  cavity.  This  when  laid  open  appears  occasion- 
ally subdivided  by  small  partial  septa,  and  contains  an 
aqueous  fluid,  which  is  capable  of  being  partly  coagulated. 
This  fluid  is  undoubtedly  supplied  by  the  secretion  of  the 
small  arteries  belonging  to  the  inner  membrane  of  the 
Fallopian  tube,  which  is  naturally  very  vascular.  It  may 
be  called  dropsy  of  the  Fallopian  tube.  The  quantity  of 
fluid  which  is  generally  accumulated  in  this  state  of  the 
Fallopian  tube  is  not  considerable,  but  sometimes,  although 
very  rarely,  it  has  been  known  to  amount  to  many  pints.* 

The  Fallopian  Tubes  terminating  in  a   Cul-de-sac. 

The  Fallopian  tubes  I  have  seen  without  any  aperture 
or  firmbriated  extremity,  from  a  defect  in  the  original  for- 
mation, and  terminating  in  a  cul-de-sac.  Under  such 
circumstances  they  were  of  course  incapable  of  performing 
their  office  as  subservient  to  generation. 

An  Ovum  in  the  Fallopian  Tube. 

The  Fallopian  tube  is  sometimes  dilated  into  a  bag 
containing  an  ovum.  This  arises  from  the  ovum  being 
stopped  in  its  progress  from  the  ovarium  to  the  uterus. 
When  it  is  so  stopped,  it  does  not  die  but  is  gradually 

*  Vid.  Portal's  Anatomie  Medicate,  Tom.  V.  p.  543. 


254 

evolved,  as  if  it  had  been  lodged  in  the  cavity  of  the  uterus. 
This,  among  many  others,  is  a  proof  that  the  uterus  is  not 
the  only  organ  which  is  fitted  to  evolve  an  ovum,  but  that 
other  parts  of  the  body  can  perform  this  office.  While 
the  ovum  is  enlarging,  the  Fallopian  tube  is  more  and 
and  more  dilated,  forming  a  thin  bag  round  the  ovum. 
The  blood  vessels  passing  to  the  ovarium  and  the  Fal- 
lopian tube  where  the  ovum  is  contained,  are  gradually 
enlarged,  in  proportion  to  the  increase  of  the  ovum,  in 
order  to  supply  it  with  a  sufficient  quantity  of  blood. 
While  this  process  is  going  on  in  the  Fallopian  tube, 
the  uterus  increases  in  bulk  so  as  to  be  fully  twice  its 
natural  size,  and  becomes  more  vascular.  The  cavity  of 
its  fimdus  is  also  lined  with  a  membrana  decidua,  and 
the  cervix  uteri  is  plugged  up  with  jelly.  The  uterus 
therefore  undergoes  a  variety  of  changes,  exactly  similar 
to  those  which  take  place  in  natural  pregnancy.  The 
ovum  sometimes  makes  considerable  progress  in  the 
Fallopian  tube,  and  has  been  known  to  advance  even  to 
the  full  period  of  gestation ;  but  more  commonly  it  dies 
at  an  early  period.  In  the  course  of  the  evolution  of  the 
ovum,  the  Fallopian  tube  has  been  known  to  rupture,  and 
the  person  to  die  from  internal  haemorrhage.  A  very 
clear  and  accurate  account  of  such  a  case  has  been  pub- 
lished by  Dr.  Clarke,  in  the  Medical  and  Chirurgical 
Transactions.* 

Hard  Tumour  growing  from  a  Fallopian  Tube. 

I  have  seen  a  hard  round  tumour  growing  from  the 
outer  surface  of  one  of  the  Fallopian  tubes.     This  when 

*  See  page  261,  Vol.  2. 


255 

cut  into  exhibited  precisely  the  same  appearance  of  str,uc- 
ture  as  the  tubercle  which  grows  from  the  surface  of  the 
uterus,  viz.  it  consisted  of  a  hard  white  substance,  which 
was  intersected  by  strong  membranous  septa.  This, 
however,  I  believe  to  be  a  very  rare  appearance  of  disease. 

Diseased  Appearances  of  the  round  Ligaments. 

The  round  ligaments  partake  of  the  inflammation  of 
the  uterus,  when "  it  is  considerable,  and  has  spread  to  its 
appendages.  They  are  also,  doubtless,  subject  to  other 
diseases,  but  these  are  very  rare,  and  have  not  fallen  under 
my  own  observation,  nor  do  I  know  of  their  having  been 
particularly  taken  notice  of  by  authors. 


SYMPTOMS. 

The  symptoms  which  attend  the  different  morbid  chan- 
ges of  the  Fallopian  tubes  are  at  present  not  known ;  and 
they  must,  from  the  circumstances  belonging  to  them,  be 
very  difficult  to  ascertain. 


CHAPTER  XX1L 


DISEASED    APPEARANCES  OF   THE   VAGINA. 

Inflammation  of  the  Vagina. 

THE  internal  surface  of  the  vagina,  riear  the  outward 
opening*,  is  frequently  inflamed,  especially  from  the  appli- 
cation of  the  venereal  poison,  but  this  hardly  ever  becomes 
the  subject  of  examination  after  death. 

Adhesion  of  the,  Sides  of  the  Vagina. 

A  very  violent  inflammation  has  sometimes  been  known 
to  take  place  in  the  vagina,  which  has  terminated  in  the 
mutual  adhesion  of  the  sides  of  the  cavity.  Thrs  adhesion 
is  sometimes  extended  over  a  great  part  of  the  cavity,  but 
I  believe  is  often  more  confined,  producing  a  stricture  in 
some  one  part. 

Ulcers  of  the  Vagina. 

Ulcerations  are  not  unusual*  in  the  vagina.  They  some- 
times appear  like  spots  of  the  internal  surface,  removed 
as  it  were  by  a  knife,  and  sometimes  there  is  a  foul 
ragged  ulcer.  When  this  last  is  the  case  in  any  considera- 
ble degree,  the  ulcer  has  commonly  not  originated  in  the 
vagina,  but  has  spread  to  it  from  the  womb.  When  the 
ulcer  spreads  very  much,  communications  are  often  made 
with  the  neighbouring  parts,  producing  a  most  miserable 
state  of  existence.  Thus  communications  are  sometimes 
formed  between  the  vagina  and  the  rectum,  or  the  vagina 
and  the  bladder. 


257 


Hard  Tumours  in  the  Vagina. 

Hard  tumours  occasionally  grow  in  the  vagina  itseli 
(although,  I  believe,  rarely)  when  the  uttrusis  unaffected. 
When  cut  into,  they  exhibit  a  structure  very  similar  to 
that  of  the  tubercle  of  the  uterus,  which  has  been  lately 
described. 

Inversion  of  the  Vagina. 

One  of  the  most  common  diseases  of  the  vagina  is  its 
inversion,  or  prolapsus:  this  is  more  apt  to  happen  wl». 
the  natural  formation  of  the  pelvis  is  large,  where  the 
ternal  opening  at  the  vulva  is  wide,  and  where  the  parts? 
are  generally  relaxed.  The  prolapsus  is  more  or  less  m 
different  cases;  in  some  the  uterus  does  not  pass  out  at  the 
external  parts,  and  in  others  the  inversion  of  the  vagina  is 
complete,  at  the  extremity  of  which  is  situated  the  os 
uteri.  The  protrusion  has  then  different  shapes;  it  some- 
times forms  a  lc^:ge  rounded  mass,  and  sometimes  it  is 
narrower  and  more  elongated,  extending,  perhaps,  five 
inches  from  the  surface  of  the  body.  When  this  last  has 
been  the  case,  it  has  been  sometimes  mistaken  for  that 
species  of  monstrous  formation  called  hermaphrodite. 
We  may  here  take  an  opportunity  of  mentioning,  that 
although  in  some  of  the  common  quadrupeds  a  real 
hermaphrodite  structure  has  occasionally  been  found,  yet 
it  has  hardly  ever  occurred  in  the  human  subject.* 

*  Although  the  examples  of  what  have  been  called  hermaphrodites  in  the 
human  species  have,  when  strictly  examined,  been  hitherto  found  to  belong 
to  the  male  or  the  female  sex;  yet  Dr.  Storer  of  Nottingham  has  favoured  me 
with  an  account  of  a  person  so  strongly  marked  as  a  hermaphrodite,  that  no 
doubt  can,  I  think,  be  reasonably  entertained  of  this  being  the  case.  The  person 
to  whom  this  singular  monstrosity  belongs,  is  still  alive,  and  has  been  carefully 

2K 


258 

When  the  vagina  has  been  long  subject  to  inversion,  its 
inner  surface  becomes  in  many  parts  drier  and  harder  than 
natural ;  it  is  likewise  apt  to  be  occasionally  inflamed  from 
external  irritation,  which  not  uncommonly  advances  to 
ulceration. 

•In  inversion  of  the  vagina  and  prolapsus  of  the  uterus, 
if  the  cavity  of  the  pelvis  be  examined,  the  fundus  only 
of  the  uterus  can  be  seen  with  its  appendages  very  im- 
perfectly, or  the  whole  of  the  uterus  is  hid  entirely  :  the 
bladder  then  appears  to  be  in  contact  with  the  rectum.  In 
this  state  of  the  uterus  and  its  appendages,  I  have  known 
adhesions  formed  between  them  and  the  neighbouring 
parts.  These  must  have  rendered  the  reduction  of  the 
uterus  and  the  vagina  to  their  natural  situation  very  diffi- 
cult, and,  perhaps,  till  the  adhesions  were  a  good  deal 
elongated,  impossible. 


examined  by  Dr.  Storer,  and  other  medical  gentlemen,  very  able  to  judge  con- 
cerning it ;  I  shall  therefore  take  the  liberty  of  inse°4ng  here,  the  account 
which  Dr.  Storer  was  so  obliging  as  to  send  me. 

The  person  bears  a  woman's  name,  and  wears  the  apparel  of  a  woman.  She 
has  a  remarkable  masculine  look,  with  plain  features,  but  no  beard.  She  had 
never  menstruated;  and  on  this  account  she  was  desired  by  the  lady  with  whom 
bhe  lived  as  servant,  to  become  an  outpatient  at  the  Nottingham  Hospital.  At 
this  time  she  was  twenty-four  years  of  age,  and  had  not  been  sensible  of  any  bad 
health,  but  only  came  to  the  hospital  in  order  to  comply  with  the  wishes  of  her 
mistress.  Various  medicines  were  tried  without  effect,  which  led  to  the  suspi- 
cion of  the  hymen  being  imperforated,  and  the  menstrual  blood  having  accumu- 
lated behind  it.  She  was,  therefore,  examined  by  Mr.  Wright,  one  of  the 
surgeons  to  the  hospital,  and  by  Dr.  Storer. 

The  vagina  was  found  to  terminate  in  a  cul-de-sac,  two  inches  from  the  ex- 
ternal surface  of  the  labia.  The  head  of  the  clitoris,  and  the  external  orifice  of 
the  meatus  urinx,  appeared  as  in  the  natural  structure  of  a  female,  but  there 
were  no  nymphs.  The  labia  were  more  pendulous  than  usual,  and  contained 
each  of  them  a  body  resembling  a  testicle  of  a  moderate  size,  with  its  chord. 
The  mammx  resembled  those  of  a  woman.  The  .person  had  no  desire  or 
partiality  whatever  for  either  sex. 


259 


The  Vagina  very  short. 

The  vagina  is  sometimes  very  short.  I  have  seen  H 
not  more  than  half  its  natural  length.  This  is  an  original 
defect  in  the  formation  of  the  part,  and  can  only  be  ascer- 
tained by  an  examination* 

The  Vagina  widened. 

The  vagina  is  sometimes  very  much  stretched  or 
widened  by  large  tumours  which  are  lodged  in  it :  these 
are  chiefly  polypi ;  and  when  they  have  been  removed  by 
art,  the  vagina,  if  it  has  not  been  for  a  long  time  stretched, 
recovers  nearly  its  natural  size. 

The  Vagina  very  narrow* 

The  vagina  has  occasionally  been  found  to  be  very 
much  contracted  with  regard  to  its  transverse  diameter, 
from  a  defect  in  the  original  formation.  This,  however, 
occurs  very  rarely,  and  may  in  some  degree  be  remedied 
by  art. 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  of  the  inner 
membrane  of  the  vagina  and  the  labia,  are  too  well  known 
to  require  any  description. 


An  adhesion  of  the  sides  of  the  vagina  can  only  be 


260 

distinctly  known  by  .an  examination.     It  may,  however, 
be  strongly  suspected  where  there  has  been  a  previous 
violent  inflammation  of  the  vagina,  and  since  that  period 
there  has  been  no  menstrual  discharge,  together  with  an 
unfitness  for  the  usual  intercourse    between 'the  sexes. 
When  the  adhesion  has  extended   over    a    considerable 
part  of  the  vagina,  it  is  hardly  possible  by  an  operation  to 
separate  the  adhering  surfaces,  and  to  restore  the  original 
canal.     I  have  known  attempts  of  this  kind  to  fail  in  the 
most  skilful  hands ;   and  it  requires  much  nicety  of  man- 
agement to  avoid  making  an  opening  into  the  bladder  or 
the  rectum.     Where  the  extent  of  the  adhesion  is  smali, 
it  is  very  capable   of  being  remedied  by  an  operation, 
except  perhaps  very  near  the  internal  extremity  of  the 
vagina.     As  it  is  impossible,  when  the  adhesion  is  com- 
plete, to  know,  a  priori,  whether  it  be  of  large  or  of  small 
extent,  it  is  almost  always  proper  to  attempt  an  operation; 
but  this  should  only  be  done  by  a  surgeon  who  is  dextrous 
in  the  management  of  the  knife,  and  with  extreme  caution. 
Where  there  is  merely  a  narrow  line  of  adhesion,   this 
may    probably   be    discovered    by  the  accumulation   of 
the  menstrual  blood  behind  it ;  and  it  is  possible  that  this 
accumulation  may  at  length  break  through  the  adhesion, 
and  render  an  operation  unnecessary,  it  would  be  absurd, 
however,  to  put  off  an  operation  which  under  such  cir- 
cumstances must  be  very  slight,  for  the  very  uncertain 
chance  of  this  effect  taking  place. 


Ulcers  in  the  vagina  can  only  be  determined  with  ac- 
curacy by  an  examination  of  that  passage  in  the  living 


261 

body.  They  are  attended  with  more  or  less  pain,  and 
with  a  discharge  of  pus;  but  both  of  these  symptoms 
belong  also  to  inflammation  of  the  vagina,  without  any 
ulceration  whatever. 


The  symptoms  attending  an  inversion  of  the  vagina, 
and  a  prolapsus  uteri  have  been  already  explained  in  the 
chapter  upon  diseases  of  the  uterus.  As  the  exact  cir- 
cumstances of  the  disease  can  never  be  known,  except  by 
an  examination  in  the  living  body,  such  an  examination 
should  always  be  strongly  recommended  to  the  patient. 


The  existence  of  tumours  growing  in  the  vagina  can  only 
be  accurately  ascertained  by  an  attentive  examination. 


CHAPTER  XXIII. 

DISEASED    AND    PRETERNATURAL    APPEARANCES     01 
THE    EXTERNAL    PARTS. 

The  Hymen  imperforated 

THE  hymen  is  sometimes  found  without  a  perforation 
in  it,  so  that  the  vagina  is  completely  shut  up  at  its  exter- 
nal extremity.  This  is  an  original  mal-formation,  which 
is  frequently  not  discovered  till  the  age  of  puberty,  when 
the  menstrual  blood  is  accumulated  behind  it.  It  is  of 
little  consequence,  as  it  can  be  easily  remedied  by  a  slight 
operation. 

The  Clitoris  enlarged. 

An  enlarged  clitoris  is  also  a  natural  deformity,  less 
common  than  the  other,  but  a  more  unfortunate  one.  At 
birth,  the  clitoris  in  such  a  case  is  often  larger  than  the 
penis  of  a  male  child  of  the  same  age.  It  has  a  well  formed 
prepuce  and  glans,  together  with  a  fissure  at  its  extremity, 
so  as  to  resemble  almost  exactly  the  external  appearance 
of  the  male  organs.  These  cases  have  given  rise  to  a 
mistake,  with  regard  to  the  sex,  and  females  have  been 
often  baptized  for  males.  On  most  occasions,  however, 
where  there  is  an  enlarged  clitoris,  the  sex  may  be  deter- 
mined by  the  following  circumstances.  The  labia  are 
well  formed,  and  when  handled,  no  round  bodies  are  felt 
in  them  like  the  testicles.  The  fissure  at  the  extremity 
of  the  glands  does  not  lead  to  any  canal  of  the  urethra ; 


: 


263 

but  under  the  glans,  and  at  the  posterior  extremity  of  the 
fissure,  there  is  an  opening  which  leads  immediately  td 
the  bladder.  I  should  believe,  that  by  putting  a  small 
straight  probe  into  this  orifice,  and  passing  it  into  the 
bladder,  it  could  be  at  once  determined,  on  most  occasions, 
whether  the  child  was  male  or  female.*  If  the  child 
should  live  to  grow  up,  the  clitoris  enlarges,  but  not  in 
the  same  proportion  as  the  penis  would  do.  Such  cases 
have  been  often  mistaken  for  hermaphrodites. 

The  Nymphtf  enlarged. 

The  nymphse  are  not  unfrequently  enlarged  beyond 
their  natural  size.  This  sometimes  happens  to  one  only, 
and  sometimes  to  both.  When  the  nymphae  are  very 
much  enlarged,  they  pass  considerably  beyond  the  surface 
of  the  body,  and  have  the  same  sort  of  covering  with  the 
labia,  losing  by  their  exposure  the  fine,  vascular,  sensible 
covering  of  the  natural  nymphae.  This  is  a  monstrous 
formation  of  no  great  consequence,  unless  the  enlargement 
be  excessive,  and  even  then  the  nymph  as  can  be  extirpated 
by  art. 

The  external  Labia  growing  together. 

The  two  external  labia  are  sometimes  united  together 
by  a  fine  line  of  junction,  at  the  upper  end  of  which  are 
situated  the  meatus  urinae,  and  the  glans  of  the  clitoris. 
This  sort  of  monstrous  formation  is  not  at  all  common, 
and  is  very  easily  remedied.  When  the  external  labia 


*  Supposing  the  child  to  be  a  female,  the  probe  will  pass  readily  throughout 
a  short  straight  canal;  but  supposing  it  to  be  a  male,  the  probe  will  neither  pass 
in  a  straight  direction,  nor  without  some  degree  of  curvature  being  given  to  ils 
shape,  and  the  canal  will  be  found  to  be  of  a  considersble  length. 


264 

are  separated  by  a  slight  operation,  all  the  parts  behind 
are  found  perfect. 

The  two  labia  are  sometimes  joined  together  by  a  con- 
tinuation of  the  common  skin,  so  that  the  appearance  of 
labia  is  lost  entirely.  This  defect  may  also  be  remedied 
by  art,  and  the  parts  within  will  be  found  to  be  well  formed. 


The  external  parts,  particularly  the  inside  of  the 
nymphae,  and  the  vestibulum,  are  subject  to  inflammation 
and  ulcers  from  common  causes,  and  especially  from  the 
application  of  the  venereal  poison.  These  diseases,  although 
they  are  very  often  the  subject  of  solicitude  during  life, 
yet  are  seldom  examined  after  death,  and  therefore  we  shall 
omit  them  here  altogether. 


It  is  unnecessary  to  subjoin  any  account  of  symptoms 
to  this  chapter. 


CHAPTER  XXIV. 


DISEASED    APPEARANCES     OF     THE     BRAIN     AND     ITS 
MEMBRANES. 

Inflammation  of  the  Dura  Mater. 

THE  dura  mater  is  sometimes  found  in  a  state  of  in- 
flammation.  When  this  is  the  case,  many  extremely  fine 
vessels  filled  with  florid  blood,  are  seen  in  the  inflamed 
portion  of  it,  which  pass  between  the  dura  mater  and  the 
cranium.  These  fine  vessels  are  seldom  so  crowded  as 
in  most  other  parts  of  the  body  when  inflamed,  which 
arises  from  the  nature  of  the  membrane  itself.  Jn  its 
natural  state  there  are  few  blood  vessels  ramifying  through 
it;  and  therefore  when  it  is  inflamed,  it  does  not  appear  so 
much  crowded  with  vessels  as  other  parts  do  which  are 
naturally  more  vascular.  Still,  however,  a  person  well 
acquainted  with  the  natural  appearance  of  the  dura  mater, 
would  be  as  much  struck  with  the  difference  of  its  appear- 
ance when  inflamed  as  he  would  be  with  that  of  any  other 
part  of  the  body. 

The  dura  mater  during  a  state  of  inflammation  some- 
times forms  a  layer  of  coagulable  lymph,  which  adheres 
to  its  inner  surface  like  an  adventitious  membrane;  but 
this  is  very  uncommon, 

When  the  dura  mater  is  inflamed,  adhesions  are  some- 
times formed  between  it  and  the  other  membranes  of  the 
brain,  so  that  for  a  considerable  extent  they  adhere 
together;  but  this  appearance  of  disease  is  also  rare.  The 
2L 


266 

reason  why  diseased  adhesions  between  the  membranes  of 
the  brain  are  rare,  probably  is,  that  coagulable  lymph  is 
seldom  formed  upon  their  surface  during  inflammation. 
This  may  be  considered  as  a  kind  of  peculiarity  be- 
longing to  the  membranes  of  the  brain,  for  they  bear 
some  analogy  to  the  membranes  which  line  the  circum- 
scribed cavities  of  the  body,  and  these  last  most  com- 
monly form  coagulable  lymph  upon  their  surface  when 
they  are  inflamed. 

It  is  not  unusual  when  the  dura  mater  has  been  inflamed, 
especially  in  consequence  of  some  external  violence,  for 
suppuration  to  take  place,  and  pus  to  be  found  covering' 
a  portion  of  the  membrane. 

The  dura  mater  is  likewise  sometimes  eroded  by 
ulceration,  but  this  is  by  no  means  frequent;  it  is  more 
common  in  violent  injuries  of  the  head,  for  a  portion  of 
it  to  become  mortified. 

Scrofulous    Tumours  connected  -with  the  Dura  Mater. 

Scrofulous  tumours  are  sometimes  formed,  which  are 
connected  with  the  dura  matter,  but  this  happens  very 
rarely.  These  resemble  precisely  the  structure  of  a  scro- 
fulous absorbent  gland,  and  occasionally  there  is  found  in 
them  a  curdly  pus. 

Spongy  Tumours  growing  from  the  Dura  Matter. 

Spongy  tumours  also  grow  from  the  dura  mater,  but 
they  are  very  uncommon.  Such  tumours,  as  far  as  I  have 
had  an  opportunity  of  examining  them,  are  pulpy  to  the 
touch,  and  of  a  distinct  fibrous  structure. 


267 

Bony  Matter  formed  in  the  Dura  Mater. 

One  of  the  most  common  diseased  appearances  of  the 
dura  mater,  is  the  formation  of  bony  laminae  in  some  part 
of  it.  These  are  generally  very  small,  being  not  larger 
than  the  nail  of  a  finger?  but  they  are  also  occasionally  of 
a  much  larger  size.  They  are  thin,  and  frequently  very 
irregular  in  their  edge.  They  are  not  to  be  found  indif- 
ferently in  every  part  of  the  dura  mater,  but  are  almost 
always  adhering  at  the  superior  longitudinal  sinus,  or  its 
falciform  process.  In  some  of  them  the  proportion  of  the 
earth  to  the  animal  part  is  larger  than  in  common  bone. 
There  is  often  one  of  these  ossifications  only ;  but  some- 
times  there  are  more  of  them.  The  falciform  process  has 
been  said  to  be  occasionally  found  almost  entirely  converted 
into  bone  ;  but  this  last  appearance  is  very  rare. 

Very  strong  Adhesion  of  the  Dura  Mater  to  the  Cranium. 

There  is  at  all  times  a  strong  adhesion  between  the 
dura  mater  and  the  inside  of  the  cranium.  This  adhesion 
is  principally  formed  by  the  small  blood  vessels  which  pass 
from  the  one  to  the  other,  and  likewise  by  a  close  appli- 
cation of  the  fibrous  structure  of  the  membrane  to  the  bone. 
In  a  natural  state,  however,  the  dura  mater  can  be  perfectly 
separated  from  the  cranium ;  yet  it  sometimes  happens 
that  the  adhesion  is  so  strong,  as  to  render  it  impossible 
to  separate  the  two  completely.  The  dura  mater  in  such 
an  attempt  is  torn  in  different  parts  into  two  laminae,  one 
of  which  adheres  to  the  bone,  and  the  other  lies  upon  the 
pia  mater.  Whether  this  preternatural  strength  of  adhe- 
sion arises  from '  a  previous  state  of  inflammation  in  the 


-~  268 

dura  mater,  or  from  some  other  cause,  I  cannot  determine; 
but  it  is  not  at  all  an  uncommon  appearance. 

• 
Diseased  Appearances  of  the  Tunica  Arachnoides. 

Diseased  appearances  of  structure  are  very  rare  in  the 
tunica  arachnoides,  and  have  almost  been  entirely  over- 
looked by  writers.  The  only  diseased  appearance  of  this 
coat  which  I  have  observed,  is  that  of  its  becoming  a  good 
deal  thicker  than  it  is  naturally,  so  as  to  be  a  tolerably  firm 
membrane.  In  this,  as  well  as  in  its  natural  state^  no  blood 
vessels  are  to  be  seen  ramifying  upon  it ;  or  at  least  they 
are  extremely  few.  It  is  also  separated  at  some  distance 
from  the  pia  mater,  by  a  serous  fluid  being  interposed 
between  the  one  and  the  other. 

Diseased  Appearances  of  the  Pia  Mater. — Veins  of  the 
Pia  Mater  turgid  -with  Blood. 

The  most  common  diseased  appearance  of  the  pia 
mater  is  that  of  its  veins  being  turgid  with  blood.  This 
depends  upon  some  impediment  to  the  free  return  of  the 
blood  from  the  head  towards  the  heart,  which  may  arise 
from  a  variety  of  causes,  and  is  very  different  from  an 
inflamed  state  of  the  pia  mater.  The  smaller  branches  of 
its  arteries,  filled  with  a  florid  blood,  are  not  more  nume- 
rous in  this  state  than  is  natural,  but  its  veins  are  much 
more  distended  with  a  dark  blood. 

The  Pia  Mater  inflamed. 

When  the  pia  mater  is  inflamed,  it  is  upon  the  whole 
more  difficult  to  distinguish  this  condition  of  it  from  its 
natural  state  than  in  any  other  membrane  of  the  body. 
This  depends  upon  the  great  number  of  very  small  vessels 


269 

which  naturally  ramify  upon  it.  In  inflammation  of  the 
pia  mater,  these  small  vessels  are  much  more  numerous 
than  in  its  natural  state,  are  filled  with  a  florid  blood,  and 
form  by  their  anastomosis,  a  beautiful  net- work.  It  does 
not  frequently  occur,  when  the  pia  mater  is  inflamed,  that 
it  becomes  so  uniformly  red  as  to  shew  no  interstices  be- 
tween its  vessels,  a  circumstance  which  happens  in  the 
inflammation  of  some  other  membranes.  The  processes 
arising  from  the  under  surface  of  the  pia  mater  are  also 
more  crowded  with  vessels  than  usual,  and  there  is  a  stron- 
ger adhesion  between  them  and  the  substance  of  the  brain. 

It  very  rarely  happens  that  any  layer  of  coagulable 
lymph  is  formed  in  the  inflammation  of  the  pia  mater 
which  is  so  very  common  in  inflammation  of  the  pleura 
and  the  peritoneum.  When  the  pia  mater  is  inflamed  to 
a  high  degree,  pus  is  cominonly  formed ;  I  have  seen  it 
effused  over  the  whole  upper  surface  of  the  brain,  in 
consequence  of  an  inflammation  of  the  pia  mater. 

Close  adhesions,  over  a  large  extent  of  surface,  have 
been  seen  between  the  pia  and  dura  mater,  which  are 
probably  the  consequence  of  inflammation ;  but  these  are 
rare,  and  have  not  fallen  under  my  own  observation. 
Adhesions  however  of  a  small  extent  are  not  very  un- 
common. 

Scrofulous  Tumours  adhering  to  the  Pia  Mater 

I  have  seen  a  number  of  scrofulous  tumours  adhering 
to  the  inside  of  the  pia  mater.  They  exhibited  the  true 
scrofulous  structure,  which  has  been  often  explained,  and 
are  very  uncommon, 


270 


9  Air  in  the  Vessels  of  the  Pia  Mater. 

It  is  not  unusual  to  find  some  of  the  vessels  of  the  pia 
mater  filled  with  air.  This  may  be  generated  by  putre- 
faction, but  it  is  also  sometimes  seen  when  no  process  of 
this  kind  appears  to  have  taken  place.  Under  such  cir- 
cumstances, it  is  probable  that  air  is  extricated  by  some 
new  arrangement  in  the  constituent  parts  of  the  blood. 

Hydatids. 

Little  cysts*  containing  water  (which  are  generally 
called  hydatids),  have  been  seen  adhering  to  the  pia  mater; 
but  this  is  a  very  rare  appearance  of  disease. 

A  Part  of  the  Pia  Mater  Bony. 

It  occasionally  happens,  although  I  believe  very  seldom, 
that  a  portion  of  the  pia  mater  is  converted  into  bone.  It 
has  not  occurred  to  me  to  observe  such  a  change  of 
structure  in  this  membrane,  but  Dr.  Soemmerring  men- 
tions that  a  specimen  of  this  disease  is  preserved  in  his 
collection. 

Diseased  Appearances  in  the  Substance  of  the  Brain. — 
Inflammation. 

The  substance  of  the  brain,  under  which  I  include 
both  the  cerebrum  and  cerebellum,  is  liable  to  inflamma- 
tion, although*  it  is  not  very  common,  when  no  external 
injury  has  been  applied  to  the  head.  When  inflammation 
takes  place,  it  is  rarely  extended  over  any  large  portion  of 
the  brain,  but  is  rather  confined  to  one  or  more  distinct 
parts  of  it.  In  this  state  of  disease  the  inflamed  portion 

'  Vid.  Lieutaud,  Tom.  II.  p.  145. 


271 

becomes  of  a  red  colour,  although  this  is  seldom  very  in- 
tense.  When  cut  into,  the  colour  is  found  to  arise  from 
a  great  many  small  vessels,  which  are  filled  with  blood. 
If  the  inflamed  portion  be  upon  the  surface  of  the  brain, 
the  membranes  in  the  neighbourhood  are  also  commonly 
inflamed.  The  part  which  is  inflamed  has  no  peculiar 
hardness,  but  yields  nearly  the  same  sensation  to  the  touch,, 
as  it  would  do  in  a  healthy  state. 

Abscesses. 

Inflammation  of  the  brain  frequently  advances  to  suppu 
ration,  and  abscesses  are  formed  in  it.  When  these. arc 
of  a  large  size,  the  weight  of  the  pus  breaks  down  the 
structure  of  the  neighbouring  parts,  and  they  look  simply 
as*  if  they  had  been  destroyed,  or  very  much  injured  by 
the  pressure.  When  the  abscesses  are  small,  there  is  an 
ulcerated  appearance  of  the  cavity  in  which  the  pus  is 
contained. 

Gangrene. 

Portions  of  the  brain  occasionally  become  gangrenous^ 
especially  after  violent  injuries  of  the  head;  but  I  believe 
this  appearance  of  disease  is  extremely  rare,  where  an 
inflammation  of  the  brain  has  taken  place  from  any  other 
cause.  I  have  met,  however,  with  one  instance  of  this ; 
a  portion  of  the  brain  at  the  inflamed  part  was  of  a  very 
dark  brown  colour,  and  as  soft  as  the  most  rotten  pear. 

The  Brain  very  soft. 

It  is  extremely  common,  when  the  brain  is  examined 
in  a  person  who  has  been  dead  for  several  days,  to  find 
such  a  softnes  of  its  substance,  that  it  can, hardly  admit  of 


being  cut,  so  as  to  leave  a  smooth  surface,  and  the  smallest 
pressure  of  the  fingers  breaks  it  down  into  a  pultaceous 
mass.  The  brain,  .however,  will  sometimes  retain,  for 
several  days  the  firmness  and  resistance  which  it  had  during 
life  ;  yet  this  is  by  no  means  common.  Neither  of  these 
appearances  is  to  be  considered  as  produced  by  disease. 
Sometimes,  however,  a  part  of  the  medullary  substance 
of  the  brain  becomes  morbidly  soft,  and  loses  its  natural 
texture,  acquiring  nearly  the  consistence  of  a  custard. 
Dr.  John  Hunter,  physician  to  the  army,  has  observed 
this  in  the  medulla  of  the  hemispheres  of  the  brain,  near 
the  lateral  ventricles.  He  has  met  with  this  appearance 
in  cases  of  fatuity,  where  the  persons  were  advanced  in 
life,  and  also  combined  with  effusions  of  blood  in  apoplexy. 
1  have  likewise  met  with  one  or  two  instances  of  the  same 
diseased  change  of  structure  in  a  part  of  the  medullary 
substance  of  the  brain. 

The  Brain  very  firm. 

The  brain  is  sometimes  found  to  be  considerably  firmer 
than  in  its  healthy  state,  to  be  tougher,  and  to  have  a 
greater  degree  of  elasticity  than  usual ;  it  will  bear  to  be 
pulled  out  with  some  force,  and  will  readily  re- act  so  as 
to  restore  itself,  or  when  pressed  will  recover  its  former 
shape.  Under  such  circumstances  the  ventricles  are 
sometimes  found  to  be  enlarged  in  their  size,  and  full  of 
water.  The  brain  has  even  been  said  to  become  so  hard  and 
dry  as  to  be  friable  between  the  fingers; 'and  the  medullary 
substance,  in  these  cases,  is  represented  as  being  much 
lighter  than  in  a  natural  state.  It  is  probable,  however, 
that  these  accounts  are  a  good  deal  exaggerated.  It  has 
been  remarked  that  in  such  cases  the  cerebellum  is  very 
often  unaffected. 


273 


A  white  firm  Substance  formed  in  the  Brain. 

It  is  not  very  unusual  to  see  a  white  substance  formed 
in  the  brain  of  an  uniform  smooth  texture,  and  possessing 
a  considerable  degree  of  hardness.  The  brain  adheres  to 
this  substance,  and  round  its  edge  appears  often  more 
vascular  than  usual.  The  substance  is  scrofulous  in  its 
nature,  for  I  have  had  an  opportunity  of  seeing  it  converted 
into  a  scrofulous  pus.  More  than  one  of  these  substances 
are  frequently  formed  in  the  brain  at  a  time. 

It  is  also  not  unusual  to  find  rounded  masses  of  the 
same  sort  of  substance,  lying  as  it  were  imbedded  in  the 
brain,  or  in  its  interstices ;  some  of  these  I  have  seen  as 
large  as  a  walnut.  When  such  tumours  are  formed,  it 
happens  frequently  that  there  is  an  increased  quantity  of 
water  in  the  lateral  ventricles  of  the  brain. 

Encysted  Tumours  and  Hydatids* 

Encysted  tumours  containing  a  serous  fluid*  have 
sometimes  been  found  in  the  substance  of  the  brain ;  but 
they  have  never  come  under  my  own  observation,  and 
are  very  uncommon. 

In  one  instance  I  have  been  informed  from  good  au- 
thority, that  hydatids  were  accumulated  in  the  lateral 
ventricles  of  the  brain,  but  this  is  still  a  more  uncommon 
apearance  of  disease  than  the  other.  They  seemed  to  be 
of  the  same  nature  with  hydatids  of  the  liver,  f 

*  Vid.  Lieutaud,  Tom.  If.  p.  194,  195. 

f  This  case  was  communicated  to  me  by  Mr.  Burnall,  who  attended  the 
patient,  and  examined  the  appearances  after  death. 


2M 


274 


Bony  Tumours  pressing  upon  the  Brain. 

Bony  tumours  are  sometimes  formed  in  the  cranium, 
which  press  upona  part  of  the  brain.  They  most  commonly 
consist  of  an  irregular  mass,  which  is  formed  of  bony 
processes,  with  a  fleshy  substance  filling  up  the  interstices 
between  them.  Of  this  sort  of  tumour  there  are  several 
examples  in  Dr.  Hunter's  collection. 


It  has  sometimes  happened,  but  very  rarely,  that  all 
the  bones  of  the  cranium  have  become  extremely  thick- 
ened, and  have  encroached,  by  their  growth,  upon  the 
cavity  which  contains  the  bruin.  Of  this  there  is  a  re- 
markable specimen  in  Mr.  Hunter's  collection,  where  the 
bones  of  the  cranium  are  at  least  three  times  as  thick  as  in 
the  natural  state.  They  are  also,  in  the  case  to  which  I 
allude,  much  more  spongy  than  usual  in  their  texture. 


A  nodule  of  a  substance  having  the  appearance  of  ivory, 
has  also  been  known  to  be  formed  in  the  bones  of  the 
cranium,  and  to  protrude  considerably  into  its  cavity. 
This  too  occurs  very  rarely,  but  a  specimen  of  it  is  pre- 
served in  Mr.  Hunter's  collection.*  Whatever  may  be 
the  variety  in  the  morbid  processes  which  produce  these 
changes  of  structure  in  the  bones  of  the  cranium,  their 

*  This  nodule  of  ivory  is  formed  in  one  of  the  orbits,  and  I  am  not  sure  whether 
it  may  not  be  the  eye  converted  into  this  substance.  The  nodule  is  of  consider- 
able size,  and  projects  some  way  into  the  cavity  of  the  cranium  behind  the  orbit, 


275 

effects  upon  the  functions  of  the  brain  must  be  nearly  the 
same,  as  they  form  a  permanent  cause  of  compression. 

Bony  Ridges  irritating  the  Brain. 

Upon  the  inner  surface  of  the  basis  of  the  cranium  there 
is  always  some  irregularity.  This  consists  in  numerous 
ridges  and  small  eminences  with  depressed  surfaces  in- 
terposed between  them.  It  happens  occasionally  that  there 
is  a  morbid  growth  of  these  eminences  and  ridges,  forming 
sharp  spicula  and  sharp  edges  of  bone.  These  run  into 
the  brain,  and  irritate  very  violently  the  nervous  system. 

Hydrocephalus. 

One  of  the  most  common  appearances  of  disease  in  the 
brain,  is  the  accumulation  of  water  in  its  ventricles  ;*  this 
generally  takes  place  when  a  child  is  very  young,  and 
even  sometimes  before  birth.  The  water  is  accumulated 
in  greater  or  less  quantity  in  different  cases.  It  some- 
times amounts  only  to  a  few  ounces,  and  occasionally  to 
many  pints.  When  the  quantity  of  water  is  very  conside- 
rable, the  fornix  is  raised  at  its  anterior  extremity  in  con- 
sequence of  its  accumulation,  and  an  immediate  opening 
of  communication  is  thereby  formed  between  the  lateral 
ventricles,  f  From  this  cause  too  a  part  o£  the  water 

*  Sir  Everard  Home  has  known  an  instance  where  water  was  accumulated  in 
large  quantity  in  the  third  ventricle,  and  had  forced  its  way  between  the  fine 
laminae  of  the  medullary  substance  which  compose  the  septum  lucidum, 
without  escaping  into  either  of  the  lateral  ventricles.  This  may  be  said  to  be 
a  new  situation  of  hydrocephalus,  and  is  of  very  rare  occurrence. 

f  A  distinguithed  author  has,  in  a  late  publication,  insisted  very  strongly 
upon  the  existence  of  an  immediate  communication  between  the  two  lateral 
ventricles  of  the  brain,  and  has  expressed  great  surprise  that  it  has  been  denied 
by  several  teachers  of  anatomy  in  London.  Without  entering  into  any  dispute 
about  this  matter,  which  in  itself  is  of  no  great  importance,  I  shall  briefly 


passes  very  readily  into  the  third  ventricle,  and  from  thence 
into  the  fourth.  The  water  is  of  a  purer  colour,  and  more 
limpid,  than  what  is  found  in  dropsy  of  the  thorax  or 
abdomen.  It  appears,  however,  to  be  generally  of  the 
same  nature  with  the  water  that  is  accumulated  in  both 
of  those  large  cavities.  In  some  trials  which  I  have  made, 
it  partly  coagulated  upon  the  application  of  the  common 
acids,  exactly  like  the  water  in  hydrothorax  and  ascites, 
or  like  the  serum  of  the  blood.  But  there  is  much  variety 
in  the  quantity  of  the  coagulable  matter.  In  some  instan- 
ces the  water  in  hydrocephalus  contains  a  small  proportion 
of  coagulable  matter,  and  in  others  it  is  almost  entirely 
free  from  it. 

When  water  is  accumulated  in  the  ventricles  to  a  very 

•< 

large  quantity,  the  substance  of  the  brain,  especially  upon 
the  sides  and  at  the  upper  surface,  is  so  thin,  as  almost  to 
appear  to  be  a  sort  of  pulpy  bag,  containing  a  fluid.  The 
scull  too  upon  such  occasions  is  very  much  enlarged  in 
size,  and  altered  in  its  shape.  The  cranium  is  exceedingly 
large  in  proportion  to  the  size  of  the  face.  The  projec- 
tions  are  very  considerable  at  the  centres  of  ossification, 


mention  what  appears  to  me  to  be  the  real  state  of  the  circumstances.  The 
fornix  at  its  anterior  extremity  lies  loose  upon  a  part  of  the  thalama  nervorum 
opticorum  and  there  is  a  small  chink  on  each  side  of  the  fornix  leading  obliquely 
downwards  from  the  lateral  ventricles  to  the  anterior  extremity  of  the  third 
ventricle.  While  the  fornix  is  allowed  to  remain  in  its  natural  situation, 
there  seems  to  me  to  be  no  immediate  communication  between  the  lateral 
ventricles.  But  when  the  fornix  is  elevated  (which  may  be  very  easily  done) 
then  the  lateral  ventricles  communicate  directly  with  each  other;  and 
the  communication  is  more  or  less  according  to  the  degree  of  the  eleva- 
tion. It  may  be  said,  that  the  lateral  ventricles  still  communicate  together 
by  means  of  the  third  ventricle.  This,  however,  is  not  properly  an  imme- 
diate communication  between  the  two  lateral  ventricles,  unless  any  two 
cavities  which  communicate  with  a  third,  may  be  properly  said  to  commu- 
nicate directly  or  immediately  with  each  other, 


277 

from  whence  the  frontal,  parietal,  and  occipital  bones  were 
originally  formed,  and  the  membranous  divisions  between 
these  several  bones  are  very  wide.  When  the  scalp  is 
removed,  so  as  to  give  an  opportunity  of  looking  imme- 
diately upon  the  cranium,  the  bones  are  found  to  be  very 
thin,  often  not  thicker  than  a  shilling,  and  there  are  fre- 
quently broad  spots  of  membrane  in  the  bone.  The 
reason  of  this  last  appearance  is  that  ossification  takes  place 
in  many  points  of  the  membrane  in  such  cases  in  order  to 
make  a  quicker  progress,  but  the  water  accumulates  too 
rapidly  for  it,  so  that  spots  of  membrane  are  left  not  con- 
verted into  bone.  When  such  appearances  take  place  in 
hydrocephalus,  the  disease  has  been  of  long  continuance, 
occasionally  for  some  years. 

Water  upon  the  Surface  of  the  Brain,  and  between   its 
Membranes. 

Water  is  also  sometimes  formed  under  the  pia  maters 
and  upon  the  surface  of  the  brain,  but  very  rarely  in  any 
considerable  quantity.  There  is,  generally,  at  the  same 
time  a  greater  quantity  than  natural  in  the  ventricles. 

The  most  common  situation  of  water  between  the 
membranes  of  the  brain,  is  between  the  tunica  arachnoides 
and  the  pia  mater.  In  this  case  the  water  is  commonly 
effused  in  small  separate  portions  between  these  two 
membranes,  and  at  other  times  is  effused  over  a  large 
extent.  The  fluid  when  seen  through  the  tunica  arach- 
noides appears  commonly  like  a  very  thin  jelly,  but  it  is 
always  a  fluid,  and  resembles  the  serum  of  the  blood. 
The  blood  vessels  of  the  pia  mater  are  generally  in  such 
cases  more  distended  with  blood  than  is  natural,  but  this 
does  not  always  occur.  The  tunica  arachnoides  is  gene- 


278 

rally  thicker  than  usual,  and  has  a  certain  degree  of  opacity . 
Sometimes  there  is  a  little  more  water  than  usual  in  the 
ventricles  of  the  brain,  and  sometimes  there  is  only  the 
natural  quantity.  Not  unfrequently  in  these  cases  there 
is  more  or  less  water  in  the  theca  vertebralis ;  but  this  does 
not  happen,  except  when  the  quantity  of  water  effused 
between  the  tunica  arachnoides  and  the  pia  mater  is 
considerable. 

It  is  related  by  authors,  that  water  has  been  formed 
occasionally  between  the  dura  mater  and  the  cranium.* 
From  the  nature  of  the  adhesion  between  the  cranium  and 
this  membrane  one  would  not  easily  be  led  to  suspect  an 
accumulation  of  water  between  them,  and  such  cases  are 
at  least  to  be  considered  as  very  uncommon. 

Air  between    the   Membranes  of  the    Brain,  and  in  its 

Ventricles. 

Air  has  been  said  to  have  been  sometimes  collected  in 
considerable  quantity  between  the  membranes  of  the  brain, 
and  even  in  its  ventricles.  I  do  not  recollect  to  have 
observed  either  of  these  morbid  appearances,  and  I  believe 
them  to  be  extremely  rare.f 

Blood  effused  or  extravasated. 

Blood  is  frequently  found  effused  within  the  cavity  of 
the  cranium  in  various  situations.  It  may  either  be  poured 
out  by  the  rupture  of  some  vessel  in  the  substance  of  the 
brain  itself,  or  into  some  of  the  ventricles.  It  is  frequently 
effused  upon  the  surface  of  the  brain,  or  upon  some  of  its 

*  Vid.  Lieutaud,  Tom.  II.  p.  229,  230. 

Vid.  Portal's  Anatomic  Medicale,  Tom.  IV.  p.  70,  and  71. 


279 

membranes.     This  is  most  apt  to  happen  where  the  effu- 
sion is  in  consequence  of  external  violence. 

The  quantity  of  blood  which  is  effused  from  the  rupture 
of  vessels  in  the  brain  is  frequently  very  considerable.  It 
is  commonly  found  in  a  coagulated  state,  and  the  texture 
of  the  brain  in  the  neighbourhood  is  often  very  much  hurt 
from  the  pressure.  Blood  is  not  equally  liable  to  be  effu- 
sed into  every  part  of  the  substance  of  the  brain.  Where 
an  effusion  has  taken  place  without  external  injury,  it  is 
almost  constantly  found  in  the  medullary  part  of  one  of 
the  hemispheres,  and  often  near  the  lateral  ventricles,  so 
that  a  quantity  of  blood  has  at  the  same  time  escaped  into 
one  or  both  of  these  cavities.  It  sometimes  happens  that 
the  brain  is  very  soft  in  its  consistence  at  the  place  of  this 
effusion,  a  remark  which  has  been  made  by  Dr.  John 
Hunter. 

When  blood  is  extravasated  within  the  cavity  of  the 
cranium  from  some  external  injury,  the. vascular  system 
is  usually  sound,  except  for  the  rupture  which  may  have 
happened.  But  when  extravasation  happens  within  the 
cavity  of  the  cranium,  without  external  injury,  the  vascular 
system  of  the  brain  is  almost  always  diseased.  It  is  very 
common  in  examining  the  brains  of  persons  who  are  con- 
siderably advanced  in  life,  to  find  the  trunks  of  the  internal 
carotid  arteries  upon  the  side  of  the  sella  turcica  very 
much  diseased,  and  this  disease  extends  frequently  more 
or  less  into  the  small  branches.  The  disease  consists  in 
a  bony  or  earthy  matter  being  deposited  in  the  coats  of  the 
arteries,  by  which  they  lose  a  part  of  their  contractile  and 
distensile  powers,  as  well  as  of  their  tenacity.  The  same 
sort  of  diseased  structure  is  likewise  found  in  the  basilary 
artery  and  its  branches. 


280 

The  vessels  of  the  brain  under  such  circumstances  of 
disease,  are  much  more  liable  to  be  ruptured  than  in  a 
healthy  state.  Whenever  blood  is  accumulated  in  unusual 
quantity,  or  the  circulation  is  going  on  in  them,  with  unusual 
vigiour,  they  are  liable  to  this  accident,  and  accordingly 
in  either  of  these  states,  extravasations  of  blood  frequently 
happen.  Were  the  internal  carotid  arteries  and  the  bas- 
ilary  artery  not  subject  to  the  diseased  alteration  of  struc- 
ture which  we  have  described,  effusions  of  blood  within 
the  cavity  of  the  cranium,  where  there  has  been  no  previous 
external  injury,  would  probably  be  much  more  rare. 

Cavities  in  the  Brain  containing  a  serous  Fluid. 

Cavities  containing  a  serous  fluid  are  sometimes  ob- 
served in  the  substance  of  the  brain.  They  almost 
constantly  occur  in  the  medullary  part  of  the  hemispheres, 
and  the  substance  of  the  brain  immediately  surrounding 
these  cavities  is  tough  and  smooth,  so  as  to  resemble  a 
membrane.  They  would  appear  to  be  the  remains  of 
the  cavities  formed  by  extravasated  blood,  in  cases  of 
apoplexy,  where  the  patients  have  not  been  cut  off  im- 
mediately, but  have  lived  afterwards  for  some  months  or 
years.  The  extravasated  blood  would  seem  in  such  cases 
to  have  been  dissolved,  and  taken  up  by  absorption;  but 
the  injury  is  not  repaired,  and  a  cavity  remains  afterwards, 
filled  with  a  serous  fluid.* 


*  I  had  an  opportunity  of  observing,  lately,  a  well  marked  case  of  this  sort, 
i  a  person  who  had  several  attacks  of  apoplexy,  and  at  length  was  cut  off  by  one 
of  them.  Dr.  John  Hunter  has  observed  a  good  many  instances  of  it,  and  a  case 
o<  urred  some  years  ago  to  Mr.  Wilson,  lecturer  on  anatomy,  whose  accuracy  is- 
well  known,  where  the  cavity  which  remained  was  of  a  very  large  size. 


281 


Aneuyrism  of  the  internal  Carotid  Arteries  on  the  Side  of 
the  Sella  Turcica. 

The  internal  carotid  arteries  are  very  apt  in  persons  of 
an  advanced  age,  to  become  ossified,  and  the  same  morbid 
change  may  be  traced  along  their  branches.  It  occurs, 
however,  very  rarely  that  they  are  distended  at  any  part 
into  an  aneurysmal  sack,  like  the  arteries  in  some  other 
parts  of  the  body.  I  have  been  informed  of  an  instance 
of  this  kind,  where  both  the  internal  carotid  arteries,  on 
the  side  of  the  sella  turcica,  were  distended  into  a  little 
aneurysm.*  One  of  these  aneurysms  was  about  the 
size  of  a  cherry,  and  the  other  was  somewhat  smaller.  It 
is  remarkable  that  in  the  only  two  instances  which  have 
come  to  my  knowledge,  of  aneurysms  being  formed  in 
the  arteries  of  the  head  and  brain,  there  has  been  an 
aneurysm  in  both  arteries  in  the  same  situation,  and  at  the 
same  time.  I  once  met  with  an  aneurysm  in  each  of  the 
carotid  arteries  at  the  origin  of  the  internal  carotids,  and 
in  the  case  just  described,  there  was  an  aneurysm  in  each 
of  the  two  internal  carotid  arteries  upon  the  side  of  the 
sella  turcica. 

Diseased  Appearances  of  the  Plexus  Choroides.—  Little 
Bags  in  the  Plexus  Choroides. 

The  most  common  diseased  appearance  of  the  plexus 
ehoroides  is  that  of  little  round  transparent  bags,  which 
adhere  to  it,  and  which  have  commonly  been  called  hy- 
datids.  They  are  generally  more  transparent  in  their  coats 
than  hydatids,  are  commonly  about  the  size  of  a  garden 

*  I  owe  my  acquaintance  with  this  case  to  Sir  Gilbert  Blane, 


282 

pea,  but  sometimes,  they  have  been  seen  as  large  as  a 
gooseberry.  From  several  examinations  which  I  have1 
made  of  them,  they  would  seem  to  be  formed  by  a  disten- 
sion of  the  vein  which  runs  along  the  edge  of  the  plexus 
choroides.  I  have  been  able  to  distend  them  fully  with 
air,  by  making  an  opening  into  this  vein,  and  inflating  air 
into  it  through  a  small  blow-pipe. 

Hound  Tumours  adhering  to  the  Plexus  Choroides. 

Tumours  sometimes  adhere  to  the  plexus  choroides. 
They  are  small  in  their  size,  of  a  round  shape,  and  occur 
but  rarely.  They  seem  to  be  of  the  same  kind  with  the 
round  tumours  which  are  sometimes  found  imbedded  in 
the  brain,  and  I  believe  are  scrofulous. 

Diseased  Appearances  of  the    Pineal    Gland. — Earthy 
Matter  in  the  Pineal  Gland. 

A  little  earthy  matter  is  almost  constantly  found  tn  the 
pineal  gland.  It  is  sometimes  in  very  small  quantity,  but 
not  unfrequently  the  quantity  is  very  considerable. .  The 
particles  of  the  earth  do  not  adhere  strongly  together,  but 
are  easily  separable  by  pressure  between  the  fingers.  This 
earthy  matter  consists  chiefly  of  phosphate  of  lime,*  and 
is  so  commonly  found  in  the  pineal  gland,  that  it  cannot 
well  be  considered  as  a  disease.  I  think,  however,  that  in 
some  instances  I  have  found  this  gland  without  any  dis- 
position of  earthy  matter. 

Pineal  Gland  said  to  be  scirrhous. 

The  pineal* gland  has  been  mentioned  by  authors  as 
being  sometimes  scirrhous.  I  have  felt  it  on  some  occa- 
sions a  little  firmer  than  on  others;  but  it  has  never  oc- 

*  See  Thomson's  System  of  Chemistry,  Val.  4,  p.  658, 


283 

curred  to  me  to  observe  that  alteration  of  structure  in  .it 
which  could  be  properly  called  scirrhous,  and  I  believe  it 
to  be  a  very  rare  disease. 

Water  in  the  Pineal  Gland. 

The  pineal  gland  has  been  found  to  be  very  much 
distended  with  a  limpid  water;*  but  this  too  is  very 
uncommon. 

Diseased  appearances  of  the  Pituitary  Gland. 

This  gland  is  very  little  liable  to  be  affected- by  disease. 
It  has  only  occurred  to  me  to  observe  in  it  one  morbid 
change.  It  was,  in  that  case,  enlarged  to  twice  its  natural 
size,  and  was  converted  into  a  substance,  possessing  an 
obscurely  fibrous  structure. 

Diseased  Appearances  of  the  Nerves. 

It  rarely  happens  that  any  of  the  nerves  within  the  cavity 
of  the  cranium  appear  diseased.  I  have,  however,  some- 
times  seen  a  nerve  a  good  deal  smaller  in  its  size  than  it 
ought  to  be,  softer  in  its  texture,  and  of  a  less  opaque 
colour ;  this  I  recollect  to  have  been  particularly  the  case 
with  one  of  the  optic  nerves  in  a  person  who  was  blind 
of  one  eye.f 

The  nerves  vary  a  good  deal  in  their  size  in  different 
persons,  as  a  part  of  their  original  formation,  without 
there  being  any  disease  whatever. 

*  Vicl.  Morgagni,  Epist.  LXII.  Art."  15. 

f  I  have  seen  an  instance  of  a  considerable  tumour  being  formed  in  a  nerve- 
The  tumour  was  very  solid  in  its  texture,  of  a  yellowish  white  colour,  and 
larger  in  its  size  than  a  goose's  egg.  The  nerve  seemed  to  be  in  some 
measure  lost  in  the  tumour,  and  in  one  part  of  it  a  fibrous  structure  could 
be  observed  pretty  distinctly,  simflar  to  that  of  a  nerve.  This  swelling  oc- 
curred in  one  of  the  axillary  nerves,  and  was  extirpated  by  Sir  Everard 
Home,  at  St.  George's  Hospital. 


284 

Mai-formations  of  the  Brain. 

These  are  the  principal  diseased  changes  which  take 
place  in  the  brain  and  its  appendages.  I  have  just  to  add, 
that  the  brain  is  subject  to  great  variety  from  original 
monstrous  formation.  A  great  part  of  what  is  usually 
called  the  cerebrum  is  sometimes  wanting,  while  the  cer- 
bellum,  and  the  medulla  spinalis  are  entire ;  sometimes 
there  is  hardly  any  vestige  of  either  the  cerebrum  or 
cerebellum,  and  the  medulla  spinalis  is  very  much  dimin- 
ished in  size :  at  other  times  there  is  a  total  want  of  the 
brain,  and  there  is  no  appearance  of  the  medulla  spinalis. 
In  this  case,  one  should  expect  a  want  of  nerves  through- 
out the  whole  body.  It  is,  however,  not  so;  nerves  are 
found  distributed  in  the  common  way,  through  the  limbs, 
and  the  dorsal  nerves  can  be  seen  arising  from  a  membrane 
somewhat  resembling  the  dura  mater  in  the  canal  behind 
the  vertebrae.  When  there  is  a  total  want  of  brain,  it 
sometimes  happens  that  there  is  a  medulla  spinalis,  which, 
however,  is  of  a  very  small  size.  In  cases  of  deficiency 
in  the  brain,  the  cranium  is  nearly  upon  a  level  with  the 
two  eyes,  and  there  is  often  upon  the  scalp  a  soft  spongy 
excrescence.  This  is  generally  divided  into  distinct  pro- 
tuberant masses,  and  is  covered  with  a  fine  skin,  capable 
of  being  rendered  very  vascular  by  injection.  When  cut 
into  the  spongy  excrescence  consists  of  pretty  large  cells, 
which  are  filled  with  a  sort  of  grumous  matter. 

There  is  also  frequently,  instead  of  this  excrescence,  a 
bag  growing  from  the  skin  of  the  scalp,  and  passing  down- 
wards so  as  to  cover  more  or  less  of  the  back  of  the  trunk. 
This  bag  sometimes  consists  of  a  fine  membrane,  with 
little  strength;  and  sometimes  it  is  rather  thick,  with 
considerable  firmness.  It  some'times  communicates  with 
the  cavity  of  the  cranium  by  a  considerable  opening  ;  and 


85 


sometimes  the  communication  is  very  small.  It  is  filled 
with  an  aqueous  fluid,  and  in  some  instances  there  is  also 
in  it  a  portion  of  the  brain. 


SYMPTOMS. 

Inflammation  of  the  dura  mater  is  not  distinguished  by 
any  peculiar  symptoms.  The  symptoms  which  belong 
to  it,  are  the  same  with  those  which  attend  inflammation 
of  the  other  membranes,  and  even  differ  but  little  from 
the  symptoms  which  take  place  in  inflammation  of  the 
brain  itself.  The  symptoms  are,  pain  in  the  head,  delirium, 
symptomatic  fever,  and  sometimes  convulsive  motions. 


When  tumours  have  been  found  adhering  to  the  dura 
mater,  or  the  other  membranes  of  the  brain,  a  long  con- 
tinued pain  in  the  head  has  commonly  been  remarked, 
sometimes  delirium,  sometimes  convulsions,  and  some- 
times, it  has  been  said,  the  ordinary  symptoms  of  apoplexy. 


Where  bony  matter  has  been  formed  in  the  dura  mater, 
with  sharp  processes  growing  from  it,  convulsive  motions 
have  very  commonly  occurred  in  various  parts  of  the  body, 
often  a  continued  pain  in  the  head,  sometimes  delirium, 
and  sometimes  temporary  fits  of  insanity. 

In  cases  where  the  veins  of  the  pia  mater  have  been 
found  turgid  with  blood,  stupor  has  very  frequently  oc- 
curred, sometimes  delirium,  and  sometimes,  even  apoplexy 
in  its  perfect  form. 


The  symptoms  of  inflammation  in  the  pia  mater,  are 
the  same  with  those  which  attend  inflammation  of  the 
dura  mater,  and  they  have  been  already  noticed. 


In  inflammation  of  the  substance  of  the  brain,  there  is 
pain  in  the  head,  delirium,  symptomatic  fever,  and  some- 
' times  coma. 

Where  an  abscess  has  been  formed  in  the  brain,  pain, 
delirium,  and  coma,  have  been  remarked,  sometimes  a 
paralysis  of  a  part  of  the  body,  and  sometimes  convulsions. 
The  last  symptom  has  been  observed  most  frequently  to 
occur  when  the  abscess  has  been  formed  in  the  tuberculum 
annulate  or  in  the  medulla  oblongata,  or  in  the  neighbour- 
hood of  these  structures,  so  that  the  pus  could  affect  them 
by  its  pressure. 

Where  the  brain  has  been  found  to  be  more  firm  and 
elastic  than  is  natural,  mania  has  been  often  known  to 
have  occurred.  I  have  been  informed,  however,  lately, 
from  the  best  authority,  that  this  state  of  brain  is  not 
common  in  maniacs ;  and  that  in  them  it  is  generally  not 
more  firm,  nor  more  elastic,  than  in  people  whose  minds 
have  always  seen  sound. 

The  symptoms  which  have  been  observed  to  attend  the 
formation  of  solid,  or  encysted  tumours  in  the  brain,  are 
a  permanent  pain  in  the  head,  which  is  occasionally  very 
violent,  sometimes  delirium,  sometimes  convulsions,  and 
sometimes,  it  has  been  said,  the  common  symptoms  of 
apoplexy.  It  is  worthy  of  remark  here,  that  when  tu- 
mours of  any  kind  press  upon  the  thalami  nervorum  opti- 
corum,  or  the  optic  nerves  themselves,  within  the  cranium, 


287 

vision  generally  becomes  impaired  in  various  ways;*  and 
that  when  tumours  press  upon  the  tuberculum  annulare, 
or  the  medulla  oblongata,  convulsions  are  very  apt  to  occur. 
In  the  case  where  hydatids  were  accumulated  in  the 
lateral  ventricles,  the  person  had  been  subject  for  a  long 
time  to  pain  in  his  head,  which  was  often  violent,  and 
towards  the  close  of  the  disease,  had  several  convulsion 
fits,  in  one  of  which  he  expired.  Neither  his  sight  nor 
hearing  were  impaired. 


The  symptoms  of  hydrocephalus,  are  a  pain  in  the  head, 
stupor,  convulsive  motions,  picking  of  the  nose,  grinding 
of  the  teeth  during  sleep,  occasional  flushings  of  the  face, 
a  motion  of  the  head  occasionally  upon  the  pillow  from  one 
side  to  the  other,  occasional  sighing,  and  towards  the  latter 
end  of  the  disease,  a  dilatation  of  the  pupils  and  squinting. 
The  stomach  is  commonly  affected  with  sickness,  and  the 
bowels  are  with  difficulty  acted  upon  by  purgative  medi- 
cines. In  the  beginning  of  this  disease,  the  pulse  is  fre- 
quent but  regular;  when  the  disease  has  made  a  further 
progress,  it  is  slow  and  irregular;  and  towards  the  latter  end 
of  the  disease,  it  becomes  again  more  regular  and  and  fre- 
quent. When  the  progress  of  the  disease  has  been  very 
gradual,  and  the  patient  has  continued  to  live  for  some 
months,  or  even  years,  the  functions  of  the  brain  have  been 
found  in  many  instances,  to  be  less  impaired  than  might 
have  been  expected,  till  near  its  close/ 


*  I  have  known  one  case  in  which  the  optic  nerves  at  their  junction  were 
pressed  by  a  tumour  as  large  as  a  gooseberry,  and  yet  the  pupils  were  not 
dilated,  nor  the  eye  sight  impaired,  till  within  a  day  or  two  of  the  person'? 
death,  There  was  only  a  very  violent  pain  in  tlfe  fore  part  of  the  hesftf 


Where  blood  has  been  effused  upon  any  of  the  mem- 
branes of  the  brain,  the  patient  is  more  or  less  in  a  comatose 
State,  according  to  the  degree  of  the  effusion,  or  the  different 
susceptibility  of  the  brain  in  different  individuals  to  be 
affected  by  pressure.  Innumerable  instances  shew,  that 
the  brain  will  have  its  functions  impaired  in  very  different 
degrees,  from  the  same  apparent  degree  of  injury. 

When  blood  is  effused  into  the  substance  of  the  brain, 
apoplexy  is  produced,  which  is  attended  with  the  following 
symptoms,  viz.  coma;  generally  stertorous  breathing;  a 
paralysis,  commonly  of  one  half  of  the  body;  and  often  con- 
vulsive motions.  The  pulse  is  slow,  full,  and  generally  very 
strong.  When  the  patient  is  not  cut  off  at  once,  but  lives 
for  some  time  after  the  attack,  the  hemiphlegia,  which  is 
almost  constantly  an  effect  of  this  disease,  is  generally  upon 
the  opposite  side  of  the  body  from  that  of  the  brain,  in 
which  the  effusion  of  blood  has  taken  place.  This  would 
seem  to  shew,  that  the  right  side  of  the  body  derives  its 
nervous  influence  from  the  left  side  of  the  brain,  and  the 
left  side  of  the  body  its  nervouS  influence  from  the  right 
side  of  the  brain.  In  a  few  instances,  however,  the  hemi- 
phlegia has  occurred  on  the  same  side  of  the  body  with 
the  effusion.* 

*  Dr.  John  Hunter  has  made  some  very  accurate  dissections  relative  to 
apoplexy,  and  its  consequences,  which  formed  the  subject  of  the  Gulstonian 
lectures,  read  by  him,  1796,  before  the  College  of  Physicians.  By  these  lectures, 
I  have  been  enabled  to  give  a  more  satisfactory  account  of  the  appearances 
connected  with  this  disease,  tfyan  I  should  have  been  otherwise. 


F  I X  I  S , 


